


! i 



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THE PRACTICE 



OF 



MEDICINE AND SURGERY. 



THE PRACTICE 



OF 



Medicine AND Surgery, 



APPLIED TO THE 



DISEASES AND ACCIDENTS INCIDENT TO WOMEN. 



By W. H. BYFORD, A.M., M.D., 

PROFESSOR OF GYN.^COLOGY IN RI'SH TTEDICAL COLLEGE, AXD OF OBSTETRICS IN THE -WOMAN'S 

MEDICAL COLLEGE ; SURGEON TO THE WOMAN'S HOSPITAL OF THE STATE OF ILLINOIS ; 

MEMBER AND PRESIDENT OF THE AMERICAN GYNECOLOGICAL SOCIETY; 

MEMBER AND EX-^^CE-PRESIDENT OF THE AMERICAN 

MEDICAL ASSOCIATION, ETC. 



f%.^ 



If 



y 



THIED EDITION. 



THOROUGHLY EEVISED AXD EE WRITTEN. 



ONE HUNDRED AND SIXTY-FOUR ILLUSTRATIONS. 



PHILADELPHIA: 

LINDSAY & BLAKISTON 

18 8 1. 




'> 



Vl ^•^'. ' ' ■ 



Enlered according to Act of Congre??, in the year 1S81, 

By LINDSAY & BLAKISTOX, 

III (lie Ofticc of the Librarian of Congress, at Washington, 1). C 



PREFACE TO THE THIRD EDITION. 



The second edition of this work was issued almost simultaneously 
Avith three Gynsecological works by authors who have become world- 
known and been quoted by all modern writers on diseases of women. 
That edition was soon exhausted, and the work has been out of print 
several years. The above-mentioned full supply of good books on 
the same subject led me to neglect my own for this long time. Many 
of my friends in the Western section of this country, and some in 
other portions have, however, so kindly and frequently urged me to 
produce another edition that I am persuaded it might be useful to 
the profession. 

The rapid progress of medical science in the last decade, and es- 
pecially that department to which this w^ork is devoted, has made so 
many changes necessary that the present edition is almost a new 
book. New chapters and subjects have been introduced, and most 
of the old ones have been rewritten. 

In many instances I have expressed opinions and counselled prac- 
tice that differ greatly from the teachings of the last edition. This 
could not be otherwise, nor do I desire that it should. Surrounded 
as I have been by such a throng of active workers, the results of 
whose labors I have tried to assimilate, my former ideas have been 
necessarily greatly modified, and I hope also improved. While 
there is much new material introduced, the omission of puerperal 
diseases and diseases of the breasts enables the author to compress 
the work into about the same size as the last edition. 

Chicago, August 1, 1881. 



CONTENTS. 



CHAPTER I. 

DISEASES AXD ACCIDENTS OF THE LABIA AXD PERIX-TirM. 

PAGE 

Adhesions of the labia, . 17 

Wounds, 18 

Sanguineous infiltration, .19 

Varices of the labia and vulva, 20 

CEdema, 20 

Phlegmon, 21 

Abscesses of the labia, 23 

Labial tumors, 23 

Hypertrophied labia, 24 

Elephantiasis, 24 

Cancer of the labia, 24 

Absence of the labia, 25 

CHAPTER II. 

PERINEUM. 

Definition, 26 

Eupture, 29 

EflTects of laceration, . . 30 

Treatment, 31 

Spontaneous cure, 32 

The immediate operation, .33 

Perinaeorrhaphv, . 35 

CHAPTER III. 

DISEASES OF THE VrLVA. 

Condylomata of the vulva, 40 

Treatment, 40 

Erythematous, papular, vesicular, and pustular inflammations of the vulva. . 41 

Treatment, 41 

Follicular vulvitis, . 42 

Cause, 43 

Treatment, .... , . .43 

Pruritus pudendi, 43 

Treatment, 44 

Corroding ulcer, 46 

Gangrenous vulvitis or noma, 47 



Vlll CONTENTS. 



Urethral excrescences, 48 

Vascular urethra, 49 

Hypertrophy of the clitoris and nyrapha, 50 

Treatment, 50 

CHAPTER lY. 

DISEASES OF THE BLADDER. 

Paralysis of the bladder, 51 

Prognosis, 51 

Symptoms, ............. 51 

Diagnosis, 52 

Treatment, 52 

Hsemorrhage from the bladder, .......... 53 

Hyperaesthesia of the bladder and urethra — Irritable bladder and urethra, . 54 

Causes, ............. 54 

Treatment, 54 

Chronic inflammation of the bladder, 55 

2sature and progress, 55 

Symptoms, 56 

Diagnosis, 56 

Prognosis, 57 

Treatment, . . . . . .57 

Stone in the bladder, 60 

Symptoms, 61 

Diagnosis, . . . . . ; . 61 

Treatment, 62 

Foreign bodies, 63 

Inversion of the bladder, 64 

CHAPTER Y. 

AFFECTIONS OF THE VAGINA. 

Absence of the vagina, 65 

Causes, . 65 

Diagnosis, 65 

Atresia vaginae, , 66 

Diagnosis, 67 

Prognosis, . . . -. 67 

Treatment of atresia, and absence of the vagina, 67 

Tumors in the vagina, . 70 

Vaginismus, 70 

Diagnosis, . 71 

Prognosis, 71 

Treatment, . . . . . .71 

Acute vaginitis, 73 

Diagnosis, 74 

Prognosis, 74 

Cause, . 74 

Treatment, 74 



CONTENTS. 



IX 



PAGE 

Chronic vaginitis, . . . .75 

Symptoms, 75 

Diagnosis, 76 

Causes, . 76 

Prognosis, 76 

Treatment, * . 77 

Puerperal vaginitis, .78 

Symptoms, 80 

Treatment, 80 

Urinary fistula, 81 

Diasrnosis, 83 

Prognosis, 84 

Treatment, 84 

Sims's operation, . . » .86 

Simons's method, 95 

Kolpokleisis, 100 

Bozeman's method, ......,,.. 102 

Entero-vesical fistula, ........... 107 

Entero-vaginal fistula, 107 

Eecto-vaginal fistula, . . . 107 

Treatment, . . , .108 



CHAPTER yi. 

MENSTRUATION AND ITS DISORDERS, 

General considerations, . . . . . 110 

Puberty, .111 

Amenorrhoea, . ^ . . . ^ . > ... . . .116 

Pathology and morbid anatomy, » . . . . . . .117 

Symptoms, 117 

Amenorrhoea from retention, 120 

Diagnosis, , . 120 

Diagnosis of retention, ..... ^ 123 

Prognosis, 123 

Treatment, 124 

Local electrization, ... ....... .128 



CHAPTER YII. 

MENORRHAGIA AND METRORRHAGIA. 



Definitions, ......... 


.... 133 


Causes, 


133 


Treatment of menorrhagia, 


. 137 


Palliative treatment, 


. 137 


Mechanical, ....... 


. 139 


Palliative treatment, Sims's method, .... 


. 139 


Curative treatment, ....... 


. 141 



X CONTENTS. 

CHAPTER YIII. 

DYSMENTORRHCEA. 

PAGE 

Definition, 146 

Diagnosis, 147 

Prognosis, 147 

Treatment, 147 

The inflammatory form, 149 

Symptoms, 149 

Diagnosis, 149 

Prognosis, 149 

Treatment, 149 

Membranous drsmenorrhoea, 150 

Symptoms, 115 

Diagnosis, 152 

Treatment, 152 

Obstructive dysmenorrhoea, 153 

Symptoms, 155 

Diagnosis, 155 

Prognosis, 156 

Treatment, . . . . : 156 

Sims's method, 157 

Peaslee's method, 159 

Dilatation, 167 

Storer's treatment, 168 

CHAPTER IX. 

METATITHMEXIA, OR MISPLACED AIEXSTRUATION AND PERIUTERINE 
H.EMATOCELE. 

Definition, 170 

Pathology, 171 

Symptoms, 173 

Diagnosis, . .' 175 

Prognosis, 176 

Treatment, 177 

Chronic retrouterine hematocele, 179 

Diagnosis, 182 

Treatment, 183 

CHAPTER X. 

CHANGE OF LIFE— MENOPAUSE AND SENILITY. 



CHAPTER XI. 

ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS. 

Causes, 188 

Symptoms, 188 

Prognosis, 189 



CONTENTS. • XI 

PAGE 

Diagnosis, 190 

Treatment, 190 

Acute inflammation of the mucous membrane of the uterus, .... 191 

CHAPTER XII. 

GENERAL CONSIDERATIONS ON UTERINE DISEASE OR HYSTEROPATHY. 

CHAPTER XIII. 

SYMPATHETIC SYIVIPTOMS OF UTERINE DISEASE. 

Sympathy of the stomach, 201 

Sympathetic disease of the bowels, 202 

Sympathetic affection of the liver, 203 

Sympathetic affections of the nervous system, ....... 203 

Accompanying manifestations of moral and intellectual perverseness, . . 204 

Syncopal convulsions — hystero- epilepsy, 205 

Moral and mental derangement, 206 

Cephalalgia, 207 

Affections of the spinal cord, 209 

Hyperaesthesia, 209 

Anaesthesia, 210 

Spasnis, 210 

Sympathetic pains in the pelvic region, 210 

Extension of inflammation to the bladder and rectum, 210 

Affections of the sciatic and anterior crural nerves, 211 

Muscular weakness, 211 

Circulatory system, 212 

Eespiration, 213 

Sympathy of the excretory organs, 214 

Mammary bodies, 215 

LOCAL SYMPTOMS. 

Pain in the sacral or lumbar region, 219 

Pain in the loins, 219 

Inability to walk, 219 

Pain in the iliac region, . 220 

Soreness in the iliac region, 220 

Pain in the side above the ilium, 220 

Weight or bearing-down pain, or uterine tenesmus, 221 

Leucorrhoea, . 221 

Amount of leucorrhoea not always proportioned to extent of disease, . . 222 

Yellow leucorrhoea, where there is abrasion or ulceration, .... 222 

How is the pain produced ? 223 

Bearing-down not always caused by displacements, 223 

Severity of suffering not commensurate with amount of disease, . . . 224 

Effects on the functions of the uterus, 224 

Pain during menstruation, 225 

Kind of pain attendant upon uterine inflammation, 225 

Cramping pain, . 225 



Xll 



CONTENTS. 



Effects of partial closure of the os uteri on menstruation, 
Manner of the flow modified by inflammation and congestion. 
Duration of the flow, 

Menorrhagia, 

Menorrhagia frequent in endocervicitis. 
AmenorAoea sometimes results, 
Function of generation affected by it, 

Sterility, 

Abortion, 

Conditions of the uterus in abortion. 
Effect upon labor, .... 
Effects upon the post-partum condition, 



PAGE 

225 

226 
227 
227 
227 
227 
228 
228 
229 
230 
231 
231 



CH.1PTER XIV. 

PATHOLOGY OF HYSTEROPATHY. 

General considerations, 233 

Mucous inflammation, 238 

Seat of mucous inflammation, 238 

Cavity of the body of the uterus, 239 

Endocervicitis, 239 

Endocervicitis with diminished size, 239 

Endocervicitis in virgins, . 240 

Endocervicitis in aged women, ......... 240 

External inflammation combined with internal in childbearing women, . . 240 

CHAPTER XY. 

ETIOLOGY OF UTERINE DISEASE. 



CHAPTER XVI. 

DIAGNOSIS. 

Position of patient for examination, ........ 246 

Digital examination, . 248 

Os uteri in the aged, 251 

Corpus uteri, 252 

A tender uterus is an inflamed uterus, 252 

Examination per rectum, 252 

Object in using the probe, 253 

Size and length of probe, . 254 

Mode of using, 257 

Length of the cervical and uterine cavities, ....... 257 

Hysterometer, 258 

Speculum, 260 

How to find the os uteri, 262 

Mwle of using the speculum, . . . . » 262 

Appearance of the OS and cervix in the virgin, 266 

Appearance of the multiparous uterus, 266 

Appearance in the aged, 267 



1 1-.^■ ' -j-iLiJ u^ 



CONTENTS. Xlll 

PAGE 

Exceptions to the appearances, 267 

Color, 267 

Appearance of secretion, 267 

Indication of mucus in abundance, . 268 

Indication from pus, 268 

Probe and speculum conjointly, 268 

Dilatation, 268 

Characteristic signs of inflammation, 272 

Diagnosis of endocervicitis, ..,,...... 273 

Diagnosis of submucous inflammation, 274 

Complication of mucous with submucous inflammation, 274 

Size of the uterus ordinarily increased — Exceptions, 274 

Atrophy as the result of inflammation, 275 

CHAPTER XYII. 

GENERAL TREATMENT OE UTERINE DISEASE. 

General treatment, 278 

Spontaneous cure, 278 

Change of general circumstances only temporary in effect, .... 279 

Supervention of acute inflammation, . 279 

Acute inflammation after parturition or abortion sometimes works a cure, . 280 

Posture, exercise, and repose, 280 

Sexual intercourse, 283 

Main objects of general treatment, 284 

General symptoms requiring special attention, 286 

Nervous prostration, 286 

Food, 288 

Nervous excitability, 288 

Ansemia, 291 

Plethora, 291 

Local congestions, 291 

Constipation, 292 

CHAPTER XYIII. 

SPECIAL TREATMENT. 

Baths, 303 

Hip-bath, 304 

Temperature of the bath, 305 

Shower-bath 305 

Sponge-bath, 305 

Injections, 306 

Manner of using injections — kind of syringe, 307 

Quantity of injection, ........... 308 

Medicated injections, . 308 

Astringent injections, 309 

Modus operandi, 309 

Frequency of using, 309 



xiv CONTENTS. 

PAGE 

Alternate astringent remedies, 310 

Temperature of injections, ^^^ 

Position of the patient, ^^^ 

Accident in injection, ^11 

Should they be used in pregnancy, , • • • 313 

Local treatment, . . . ''^^ 

Topical depletion, ^1^ 

Leeches, 31d 

Scarification, ^1^ 

Glycerin, ^1^ 

Local alteratives, 319 

Treatment of endometritis, 323 



CHAPTER XIX. 

LACERATIONS OF THE CERVIX UTERI. 

General considerations, 329 

Causes, 329 

The degree, locality, and direction, . 330 

Effects of the laceration, 331 

Effects on the body of the uterus, . . 331 

Complications, 332 

Symptoms, 332 

Diagnosis, 332 

Treatment, 333 

Preparatory treatment, 333 

The operation (trachelorrhaphy), 334 



CHAPTER XX. 

OCCASIONAL UNTOWARD EFFECTS OF UTERINE MANIPULATIONS AND 
OPERATIONS. 



CHAPTER XXI. 

HYPERTROPHY OF THE CERVIX. 
Elongation of the supravaginal cervix, 342 

CHAPTER XXII. 

PERIMETRITIS. 

General considerations, 346 

Causes, 349 

Symptoms, 349 

Diagnosis, 352 

Prognosis, 354 



CONTENTS. XV 

PAGE 

Local peritonitis, 355 

Causes, 357 

Symptoms, 357 

Diagnosis, 358 

Prognosis, 360 

Treatment of perimetritis, 360 



CHAPTER XXIII. 

CHRONIC PERIMETRITIS. 

Causes, 365 

Varieties, . 365 

Symptoms and diagnosis, 368 

Treatment, 369 



CHAPTER XXiy. 

DISPLACEMENTS OF THE VAGINA, BLADDER, AND RECTUM. 

Cystocele, 372 

Kectocele, 372 

Diagnosis, 373 

Causes, 373 

Treatment, 374 



CHAPTER XXV. 

DISPLACEMENTS OF THE UTERUS. 

IS^atural uterine supports, . 377 

Causes of displacements, 378 

Lapse, 379 

Prolapse, 380 

Protrusion, 381 

Symptoms, i ... 383 

Diagnosis, 384 

CHAPTER XXYI. 

DISPLACEMENTS OF THE UTERUS, CONTINTJED. 

Treatment of displacements of the uterus, 386 

Instruments, 388 

Supporters, 389 

Pessaries, 390 

Suspension pessaries, 395 

Adaptation of pessaries, 396 

Anteversion, . 396 

Ketroversion, 396 

Treatment of prolapse, 400 



XVI CONTENTS. 



CHAPTER XXYII. 

DISPLACEMENTS OF THE UTERUS, CONTINUED. 

PAGE 

Eetroversion and retroflexion of the uterus during pregnancy, . . . 407 

Causes, 407 

Symptoms, 408 

Diagnosis, 409 

Termination, 409 

Treatment, 410 

CHAPTER XXVIII. 

DISPLACEMENTS OF THE UTERUS, CONTINUED. 

Inversion of the uterus, 412 

Symptoms, • 413 

Diagnosis, 414 

Prognosis, 415 

Treatment, 416 

The treatment of the chronic form, 418 

CHAPTER XXIX. 

DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS. 

Diseased deviations of involution of the uterus, 428 

Definition, 428 

Causes, 429 

Symptoms, 429 

Prognosis, 429 

Treatment, .430 

Subinvohition of the uterus, 433 

Causes 435 

Frequency of its occurrence, 436 

Symptoms and diagnosis, 436 

Diagnosis, 437 

Prognosis, 438 

Treatment, 438 

Hyperinvolution, 441 

Causes, 441 

Symptoms, 442 

Diagnosis, 442 

CHAPTER XXX. 

CANCER OF THE UTERUS. 

General considerations, 443 

Symptoms, 445 

Causes, 447 

Diagnosis, 448 

Prognosis, 450 

Treatment, 450 

Palliation, 458 



CONTENTS. XVll 

CHAPTER XXXI. 

EPITHELIOMA, CANCROID, EPITHELIAL CANCER OF THE UTERUS. 

PAGE 

Definition, 464 

Diagnosis, 466 

Prognosis, 468 

Treatment, 468 

CHAPTER XXXII. 

SARCOMA. 

Description, 478 

Symptoms, 478 

Diagnosis, 479 

Prognosis, 480 

Treatment, ■ ... 480 

CHAPTER XXXIII. 

TUMORS OF THE UTERUS. 

Fibrous tumors, 481 

Theirnature, 483 

Symptoms, . 486 

Diagnosis, 489 

Prognosis, 491 

CHAPTER XXXIY. 

FIBROUS TUMORS OF THE UTERUS, CONTINUED. 

Treatment, 496 

Cases, 500 

Summary of cases cured by absorption, . 515 

Modes of using ergot, 516 

Different preparations, 518 

Auxiliary treatment, 520 

Corrective treatment, 521 

Modus operandi, 521 

Electrolysis, 529 

CHAPTER XXXY. 



SURGICAL TREATMENT. 

Kemoval of polypoid tumors, 531 

Enucleation, 536 

Laparotomy, 541 

Laparo-hysterotomy, 542 

Oophorectomy — Battey's operation — spaying, 546 

Physical and psychical results, 552 



XVm CONTENTS. 

CHAPTER XXXVI. 

THE OVARIES. 

PAGE 

Description, 553 

Method of examining the ovaries, 553 

CHAPTER XXXVII. 

AFFECTIONS OF THE OVARIES. 

Congenital atrophy, 555 

Hypertrophy, 555 

Displacements, 555 

Symptoms, 557 

Diagnosis, 558 

Prognosis, ............. 558 

Treatment, 559 

Ovariiis, . 561 

CHAPTER XXXYIII. 

AFFECTIONS OF THE OVARIES, CONTINUED— OVARIAN TUMORS. 

Nature and anatomy, ■ . . . . 565 

Dermoid tumors, 567 

Theories of their origin, 574 

Progress and termination, 580 

Causes, 582 

Prognosis, 584 

Diagnosis, 585 

General remarks on diagnosis of ovarian tumors generally, .... 585 

Microscopical examination of ovarian fluid, 591 

Differential diagnosis, 594 

CHAPTER XXXIX. 

OVARIAN TUMORS, CONTINUED. 

Treatment, • 602 

Palliative, 603 

Tapping, ■ 604 

Injection of the sac, 615 

Electrolysis, 621 

Vaginal ovariotomy, 622 

CHAPTER XL. 

OVARIAN TUMORS, CONTINUED-GENERAL OBSERVATIONS. 

Abdominal ovariotomy, 624 

Treatment of the pedicle, 624 

The ligature, 626 

Drainage, 627 



CONTENTS. XIX 

CHAPTER XLI. 

ABDOMINAL OVARIOTOMY, CONTINUED. 

PAGE 

Inflammation in the tumor, 628 

Complicated with pregnancy, 629 

Complications with organic disease, . . ■ 637 

Ovariotomy, 643 

CHAPTER XLII. 

OVARIOTOMY, CONTINUED. 

Accidents that may occur during the operation, 650 

CHAPTER XLIIL 

OVARIOTOMY, CONTINUED. 

After-treatment, 654 

Treatment of the wound, 655 

Attention to the clothing, 655 

Anodynes, 656 

Tympanites, 657 

Haemorrhage, 659 

Traumatic peritonitis, 660 

Septicaemia, 662 

Treatment, 663 

Eemarks and personal statistics, 664 

CHAPTER XLiy. 

FALLOPIAN TUBES. 

Inflammation, 666 

Dyopsy, . . 667 

CHAPTER XLY. 

COCCYGODY^NIA, COCCY^ILGIA. 

Neuralgia of the coccyx, 668 

Structure affected, 668 

Symptoms, 668 

Diagnosis, 669 

Prognosis, 669 

Treatment, 669 

CHAPTER XLYI. 

ELECTRICITY. 
Static, galvanic, farad ic, .671 



DISEASES AND ACCIDENTS 



INCIDENT TO AYOMEN. 



CHAPTEE I. 

DISEASES AND ACCIDENTS OF THE LABIA AND PERIX^UM. 

Adhesiox of the labia, and consequent occlusion of the vagina, 
sometimes occurs in infancy, or early childhood, as well as in adult 
life. The adhesions of infancy are so feeble and easily broken up, 
that they may be considered a trifling affair. Upon examining the 
parts, it will be found that there is no development of adhesive 
tissue, but the mucous membrane of the two sides is merely in strong 
coaptation. It probably is caused by the adhesive influence of 
mucus accumulating and drying between the parts, when in close 
contact, from want of cleanliness. The vaginal oritice is closed up 
to the urethra above, and down to the fourchette below. The treat- 
ment consists in separating the labia, by forcibly pressing each iu 
opposite directions, until the adhesion gives way, washing and oiling 
them once a day afterwards to keep them from adhering again. 
Should we not be able to separate them in this way, the point of a 
silver catheter may be passed down so as to effect it. There will be 
no need of any other instruments in the case. 

On one or two occasions I have seen firm tissual cohesions of the 
labia in childhood as the effect of ulcerative vulvar inflammation. 
This form of adhesions may be so firm as to require the use of the 
knife. They are, however, always superficial, and we may gener- 
ally introduce a bent probe or director behind the adhesions from 
above. When this is the case, it is, I believe, the best plan to sepa- 
rate them, by drawing the bent director through the adherent part. 
The same care as in the infant will prevent them from adhering 
again. 

2 



18 DISEASES AND ACCIDENTS OF THE LABIA. 

The most grave adhesions we meet are in the adult, as the effect of 
neo'lected inflammation of the vulva after childbirth. These adhe- 
sions are sufficient entirely to close the vaginal orifice by the coapta- 
tion and firm accretion of the entire inner surfaces of the labia. I 
have met with more than one instance in which the hairy margins 
of the labia were so nicely adjusted to each other, that you could not 
distinguish the point of original separation, from the perinseum to 
the urethral orifice, and the finest probe would not enter the vagina 
anywhere. The depth of the adhesion may be very great, involving 
much of the vaginal cavity. 

These cases are very embarrassing, and are seldom perfectly reme- 
died. It is decidedly the best plan not to interfere with them until 
the menstrual accumulation fills up all the vaginal cavity remaining 
inadherent, and then our object should be to reach the accumulation 
with a small trocar as near the middle of the adherent parts as pos- 
sible. Placing our patient in the lithotomy position, the catheter 
should be introduced into the urethra, the urine all drawn off, and 
the urethra held as near the symphysis pubis, or as far from the 
middle line of the vagina, as practicable. The catheter should be 
thus held by an assistant, while the forefinger of the left hand should 
be placed in the rectum. With this preparation we may safely in- 
troduce the trocar into the collection of fluid as felt by the finger. 
The fluid being drawn off, the outer extremity of the perforation 
may be increased by the knife as far as may be desired, and as deeply 
as the surgeon may consider it safe. The opening may be increased 
as much as necessary by wax or hard-rubber bougies. The whole 
cavity should be thoroughly cleansed by a syringe with soap and 
water. The size of the bougies should be increased as often as once 
in twenty-four hours. If the opening is superficial, the treatment 
will not be protracted ; but if it is deep, it will be tedious. It should 
be continued until all danger of closure is past, and it will be best to 
keep the patient under our supervision for some time after this ap- 
pears to be the case. 

Wounds. 

The labia are sometimes wounded by accidents of some kind ex- 
traneous to the patient, and they are sometimes torn during labor. 
When the wound is deep enough to reach the bulb of the clitoris, 
alarming and sometimes fatal haemorrhage is the result. Professor 
Meigs gives an instance of great haemorrhage from these parts in a 
woman who had fallen upon a chair so as to cut through one of the 



SANGUINEOUS INFILTRATION. 19 

labia. A case of fatal liaemorrhage was caused in this city about 
four years since, in the following manner, as well as it could be 
learned from a le^^al investigation : A drunken husband returned 
home late at night, and, as was his wont under such circumstances, 
beat and kicked his wife, who was probably also inebriated. He 
kicked her with great violence in the genitals^ and the square-toed 
heavy boot, in penetrating the pelvis, had cut off one labium and 
deeply wounded the other. In six or eight hours after the occur- 
rence the woman was found dead, with such copious effusion of blood 
from the wounds as, in the opinion of the examining jury, to account 
for the fatal result. I saw a case many years ago, where the patient 
was wounded by a knife in one labium so as to cause very profuse 
haemorrhage. 

The hsemorrhage being the important effect of these wounds, our 
efforts should be directed to its suppresssion, and this may in most 
cases be easily accomplished. The bleeding part should be pressed 
by the hand firmly against the pubic ramus of the side upon which 
it is situated until temporarily arrested, when an elastic air-bag or 
plug of oiled cotton or lint, may be introduced to fill up the vagina, 
and a hard compress placed and held firmly by bandages, so as to press 
the wounded part between the two. When wounds of the labia are 
large and gaping, the hair should be removed, and the wound treated 
according to ordinary rules for external wounds. The rents occur- 
ring in labor do not, in the great majority of cases, require any 
special treatment, cleanliness and quiet being all that is required. 

Sanguineous Infiltration. 

During labor, when the parts are stretched to their utmost extent, 
some of the arterial twigs occasionally give way and extravasate the 
blood in the loose structure of one labium. The infiltration usually 
shows itself after the child has been delivered ; but sometime^, before 
the head has passed, the swelling becomes very great, and proves an 
obstacle to the expulsion of the head. When this last is the case, the 
blood is effused from a large branch of the pubic artery, and the 
forcible injection into the tissues is so extensive as to fill a large part 
of the space between the vagina and the pelvic walls. This is a 
very serious state of affairs, and calls for prompt and judicious inter- 
ference. I once saw, in consultation, a case of this kind, so exten- 
sive as to arrest labor for several hours. These effusions, however, 
do not always call for surgical treatment, but when, as in the case here 



20 DISEASES AND ACCIDENTS OF THE LABIA. 

alluded to, the effusion is extensive, we must make a free incision in 
the inner surface of the labium and allow the blood to escape ; if it 
is coagulated, we should introduce the fingers and dislodge it. Water- 
dressing, some evaporating lotion or cooling discutieut wall be suffi- 
cient, and absorption will be effected in from one to four weeks. 
Suppuration occasionally, I think not frequently, is excited by a 
small amount of effusion. This should be treated as an abscess. If 
the amount of blood is great and the parts are tensely distended even 
after the child is expelled, it is better to liberate it by incision, for 
fear of sloughing or extensive suppuration and serious damage. 

Varices of the Labia and Vulva. 

This condition of the vulva may be of greater or less extent. Gen- 
erally the varicosities are scattered about on the inner side of the 
greater labia ; sometimes only one or two exist of any size, but occa- 
sionally one labium is permeated by large blue veins in every direc- 
tion until they seem to have almost entirely replaced the other tissue. 

When the venous enlargement is great there is danger of rupture 
and profuse haemorrhage, even enough to bring about fatal results. 
The veins are especially large during pregnancy, and if wounded re- 
quire prompt and energetic treatment. For the emergency, pressure 
on the point of rupture will enable us to immediately arrest the 
haemorrhage. The ligature, however, will be necessary to secure the 
patient from an immediate repetition of the accident. This should 
be applied so as to completely control the loss. The radical cure re- 
quires the obliteration of the veins, effected in the same manner as 
elsewhere, by injection with the persulphate of iron, ligating with or 
without pins, etc. A radical cure should never be attempted in the 
absence of pregnancy, unless demanded by some great emergency. 

(Edema. 

The distensible nature of the structure of the labia renders them 
liable to great oedematous infiltration in cases of general dropsy. 
Ordinarily, such distension is a matter of trifling importance, but the 
supervention of labor at a time when they are very largely swollen 
is often an embarrassing condition. They are sometimes so swollen as 
to occlude the vaginal entrance, and yield only after protracted efforts, 
and even then, sometimes, only after one of them has been more or 
less torn. When excessive oedema is discovered before the head 
presses upon the external parts or even then, no time should be lost 



PHLEGMON OF THE LABIA. 21 

in taking measures to lessen their size. This may be best done by 
everting first one and then the other, and making from ten to twenty 
small punctures through the mucous membrane only. A very sharp- 
pointed knife, taken between the thumb and finger of the right hand, 
so as to show only about the eiglith of an inch, is the best instru- 
ment. Several quick, smart strokes with the instrument thus held, 
suffice for the operation. The serum exudes from the punctures, and 
in half an hour the swelling is very much reduced. 

Phlegmon, 

Abscesses in the labia are apt to occur in three different forms. 
The first is common phlegmonous inflammation, occurring in the 
central part of one labium, very rarely in both. The heat, swelling, 
and pain are very great, and the inflammation runs its course quite 
rapidly, generally suppurating and discharging in from six to eight 
days. This form of inflammation results from bruises, acrid dis- 
charges from the vagina, or the extension of inflammation from that 
cavity. It is located about the centre of the labium, and the swell- 
ino^ and tenderness are o;reat from the bes-innino;. The second form 
originates in overdistension of Duverney's gland, from a stoppage of 
its excretory duct. It is situated deeply at the lower or posterior 
end of the labium, and generally more slow in its progress. If the 
patient is intelligent, and has observed the case with care, she will 
tell us that there was a little tumor in the seat of disease for several 
days, sometimes weeks, slightly tender at first, but gradually becom- 
ing more so until the abscess was fully formed. In this stage the 
labium is enlarged, tender, and hot, but there is not the acuteness of 
inflammation that is seen in the first variety. If the surgeon has an 
opportunity to examine the parts during the progress, he will per- 
ceive a well-defined tumor, pyriform in shape, with the small ex- 
tremity directed to the vulva, while the larger passes beneath the 
ramus of the ischium. It will not seem to be, as it is not, in the 
central part of the labium, but beneath its under surface. It will 
bear handling somewhat freely, and by pressing against the ramus, 
and directing the pressure toward the vulvar end of it, the contents 
may sometimes be pressed out. The contents in the early stages are, 
for the most part, mucus. If examined later, the surrounding parts, 
the labium particularly, will be found in a state of phlegmonous in- 
flammation, which, in ten days or two weeks, suppurates, and the pus 
is evacuated spontaneously. In this form of inflammation, if the duct 



22 DISEASES AND ACCIDENTS OF THE LABIA. 

of the gland can be opened before the inflammation becomes consid- 
erable, suppuration may be avoided. This may be done by pressing 
the fluid out, or introducing a very small probe into the canal of the 
gland, thus opening it. If these are both impracticable, it is better 
to puncture it and squeeze the contents through the outlet thus made. 
If inflammation has begun, we may treat it like the former variety, 
with leeches, purgatives, evaporating lotions, etc., in the earlier period, 
find afterwards by poultices and anodynes until the suppuration is 
complete, when it should be evacuated by puncturing it on the mu- 
cous surface of the labium. The third variety is characterized by a 
succession of small furunculi. They first show themselves as small 
points of induration immediately below the mucous membrane or 
skin, which are very tender, and in the course of a few days suppu- 
rate. One scarcely passes through these stages before it is succeeded 
by another, and thus a continuation of them prolongs the march for 
weeks, and even months, before they cease to return. This condition 
has existed only in such of my patients as were the subjects of some 
form of uterine disease, attended with leucorrhoea. They are gener- 
ally anaemic, constipated, and dyspeptic. The radical treatment con- 
sists in curing the disease of the uterus, correcting the state of the 
bowels by mercurial and saline cathartics, and reinvigorating the 
patient by the judicious employment of tonics. We may palliate the 
siiflerings of the patient by cleanliness, as bathing the parts thoroughly 
several times a day with pure cold water, and using cold-water in- 
jections per vaginam, and making such application to every hardened 
point as soon as it shows itself as will arrest its progress. I have 
used successfully the strong tincture of iodine applied to the part, 
and the solid nitrate of silver. If either of these applications is used 
as soon as the inflammation begins to come, sometimes it will be 
arrested, and the patient escape for several days, or until another 
begins to form. Should we be unable to thus cut short the inflam- 
mation, we must use poultices of bread mixed with a solution of 
acetate of lead, and anodynes, until suppuration is perfect. These 
small points of suppuration usually break themselves, and they will 
seldom be lanced. Notwithstanding the fact that inflammation of 
the labia is very painful, the patient will bear her distress until sup- 
puration is complete, or at least unavoidable in almost all cases, so 
that our treatment is confined generally to that appropriate to the 
suppurative stage. The whole process of inflammation is rapid, so 
that this may be an additional reason why the first stage is not the 
subject of observation. 



ABSCESSES OF THE LABIA — LABIAL TUMORS. 23 

Abscesses of the Labia 

Sometimes become chronic, especially such as find their origin in 
Huguier's gland. An interesting case of this kind is recorded in the 
Gynaecological Journal of Boston, second volume, page 136, by Dr. 
H. E. Storer : 

" For many years the lady had found coitus almost impossible, owing 
to occlusion of vulvae opening by lateral pressure. She was now several 
months pregnant, and the labial tumor was rapidly increasing. The 
tumor was very irregular in outline, with lobulations and depressions such 
as might easily have been occasioned by convolutions of intestine within a 
thin hernial sac. There were present many symptoms of strangulated her- 
nia, and the patient's distress and local suffering were extreme. It was 
impossible, by the most careful examination, to make a positive differen- 
tial diagnosis, though Dr. Storer was strongly inclined to believe it was a 
labial abscess of many years' standing, taking its rise from inflamma- 
tory obliteration of the duct of Huguier's gland. He cut carefully 
down upon the most presenting portion of the tumor, and obtained a 
free discharge of fetid pus. The sac was treated by carbolized tents, 
and the patient made a rapid recovery." 

Labial abscesses become chronic in another way; the duct of Hu- 
guier's gland becomes obliterated ; an abscess and discharge of pas 
take place by spontaneous eruption ; the opening closes, and this is 
followed by reaccumulation, rupture, etc., and this is repeated for an 
indefinite length of time. This form of chronic abscess is best treated 
by laying the sac open freely and emptying at once, or keeping it 
open until the contents are evacuated, and then every second or third 
day injecting a solution of nitrate of silver or tincture of iodine, or 
some other irritant that will awaken granular inflammation in the 
lining membrane of the sac. This kind of treatment should be per- 
severed in until the cavity is obliterated completely. 

Labial Tumors 
Do not diifer in any important respects from those observed in other 
parts of the body. In structure they may be fibrous, fatty, or en- 
cysted. The latter kind I have met with more frequently than either 
of the others. The fibrous are next in frequency, and the fatty per- 
haps least. In no respect does the treatment differ from the treat- 
ment of the same kind of tumors elsewhere. They should be dis- 
sected out thoroughly, no portion of tumor or cyst being left behind 
from which to be reproduced. The vulvo-vaginal gland is occasionally 
developed into a cystic tumor by the closure of the duct through 



24 



HYPERTROPHIED LABIA — CANCER OF THE LABIA. 



Fig. 1. 



which its contents are evacuated. This and the other forms of en- 
cysted tumors of tlie labia may be treated by evacuation and stimu- 
lating injections until the sac is obliterated. 

Hypertrophied Labia. 

The labia are sometimes hypertrophied, without much alteration 
of structure, to such a degree as to become cumbersome and trouble- 
some, requiring amputation. This 
may be done by the knife or ^cra- 
seur according to the shape and size 
of the superfluous part. 

These organs are very rarely the 
seat of elephantiasis, Fig. 1 (Scan- 
zoni). They sometimes are enlarged 
by this disease lo an enormous size, 
extending down to the knees, as 
shown in the figure taken from 
Scanzoni. If we meet with this af- 
fection before it has involved too 
much of the substance of the parts 
to be completely excised, we are 
justified in removing it; but if the 
skin on the thighs or abdomen is 
affected, so as to require extensive 
and dangerous dissection, we should 
not operate for this purpose, but 
content ourselves by palliative 
treatment, cleanliness, anodyne lo- 
tions, etc. It should be remem- 
bered while considering the pro- 
priety of removing small tumors 
of this kind that they very often 
return and resist every species of 
treatment. 

Cancer of the Labia 
Is not of unfrequent occurrence. 
I have only seen the epithelial 
Fromscanzonrs variety in this locality. Two cases 
have come under my observation 
within three years. The last one was a Scotch woman fifty-one years 




Elephantiasis of llic Laljia 

Dinamcs of Women 



mnmmm 



CANCER OF TOE LABIA. 



25 



of acre. The disease was located on the left side. When I first saw 
it the whole left labium presented an appearance so similar to a case 
illustrated by Fig. 2, in Dr. !McClintock's work on women, that I 
have availed myself of that figure. In my case the disease was on 
the opposite side. AVhen the disease has not advanced so far, but 
that it may all be removed, we are justified in excising it. We 
should be very particular to remove all the morbid substance. Scir- 



FlG. 2. 




rhus probably very rarely invades the labia majora. Dr. McClintock 
gives one case only. It does not seem, from the consultation of other 
authors, they have often met with it. The soft or fungoid variety 
seems to occur with even less frequency than the hard form of cancer. 
Cancer of the labia is attended with similar symptoms, and presents 
the same appearances that it does in any other organ. I need not 
stop to give it more attention in this place. 
Absence of the labia is very rarely observed. 



26 PERINEUM. 



CHAPTER II. 



PEKIX-EUM. 

"Midway between the posterior vulvar commissure and the anus. 
Those perineal structures which meet there become, as it were, fused 
together by a great accession of elastic tissue without altogether losing 
their identity; the result is a body or structure at once highly elastic 
and resistant." 

This is Savage's definition of the periu^eam. The structures are 
the superficial and deep fascia of the pelvis, portions of the levator 
ani, internal and external sphincter ani, transversalis perinei, con- 
strictor vagina, and connective tissue. As are all other structures 
associated with the genital organs, it is richly supplied with vessels 
and nerves. The vessels are so numerous and large that when in- 
jected during pregnancy this body becomes softer, more elastic, and 
distensible, and, in fact, undergoes a sort of hypertrophy, less marked, 
but not less real, than the uterus and ovaries. 

The bilateral halves of the perineal tissues unite in the centre of 
this body, and their junction corresponds with the raphe as marked 
out on the skin. This central line is the weakest part of the peri- 
nffium, and is the track pursued by lacerations in a great majority of 
instances. The perinseum is suspended in its position by the differ- 
ent muscular, fascial, and tendinous organs and tissues which con- 
verge to it. It is, therefore, displaceable, and is, in fact, easily dis- 
placetl by force applied to it in any direction. In defecation it is 
often displaced forward. It is moved out of its normal position bv 
the downward displacement of the contents of the pelvis and tlie 
contents of the uterus as they are expelled during labor. The elas- 
ticity of its attachments quickly restore it after the forces has'e been 
withdrawn. The displacements are usually greatest in the direction 
from the weakest points of attachment. In labor and displacements of 
the pelvic organs it is pushed downward and backward toward the anus. 

AVhen split in the centre each half has the appearance of an irregu- 
lar triangle. The side next the vagina is nearly twice the leuoth of 
either of the other two sides and decidedly convex. The posterior 
portion of the triangle, or the side in contact with the rectal tissues, 
is shorter than the anterior, while the lower one next the inteoument 
is still shorter and slightly conclave. 

Situated at the bottom of the pelvis, between the rectum and 
vagina, it forms the floor of that cavity. Its upper angle is not 
directed upward but obliquely backward, with reference to the centre 



PERINEUM. 



27 



of gravity, and if extended would strike tlie lower part of the sacrum. 
Its anterior angle in many instances, when normal, extends forward 
nearly to the symphysis, while its posterior angle, when the rectum is 
empty, points toward the coccyx. 

It will be seen by looking at the figure that the vaginal convex 
side is the part upon which the viscera above have their bearing. 

While considering the perin?eum the floor of the pelvis, we must 
not forget that it antagonizes the diaphragm and abdominal muscles 
and is a part of the wall of the great infrathoracic cavity. For while 
that cavity is divided into the abdominal and pelvic they are con- 
tinuous, and some of the organs of the abdomen in the usual condition 



Fig, 




(Thomas.) 

of things extend into the pelvic cavity, and in pregnancy the pelvic 
organs rise into and fill up the abdomen. 

The impairment of the tone, or a loss of a portion or the whole of 
its structure, has a similar effect to the loss of tone or a portion of 
the structure of the abdominal wall. It permits the contents of the 
abdomino-pelvic cavity to pass out just as hernia is produced by a 
deficiency in the abdominal parietes. 

The shape, size, and firmness of different perinsei differ very greatly. 
This body indicates with some degree of correctness, the muscular 
vigor of the patient. In strong, muscular women it is apt to be 
thick, strong, and unyielding, and is probably more frequently lacer- 
ated than in weaker persons. 

In women of low muscular development it is often almost useless 
as a means of support. Its firmness and efficiency are also depen- 



28 PERINEUM. 

dent upon the age and general condition of the patient. It keeps 
pace with the development of the genital organs. In early childhood 
it is rudimentary in structure and size ; stronger in youth ; com- 
pletelv developed in the middle period of life, and becomes atrophied 
in old age. In pregnancy it becomes thicker and stronger, through 
a species of hypertrophy, to successfully resist the continued pressure 
of the diaphragm and abdominal muscles. A very short time 
before labor it becomes more than ordinarily vascular and distensible. 

After labor its vascularity subsides, it undergoes a process of invo- 
lution, which results in the removal of its redundant tissue, it be- 
comes dense and resisting. At this time the lax condition of the 
alxlomiual walls and consequent diminution of pressure from that 
direction favors complete involution of theperin^eum. 

The consideration of the antagonism of the abdominal muscles and 
the perinseum would lead us to question the propriety of using a tight- 
fitting binder after labor. The binder when snugly applied restores 
the abdominal tension, while the perineum is weak and unable to 
resist the downward pressure. 

I think the binder when applied in the usual way is of doubtful 
value, because it interferes with that freedom of circulation intended 
by nature, pressing the uterus lower in the pelvis and retarding the 
involution of all the organs concerned. 

The position and relationship of the peringeum are such that it 
partakes of all the morbid influences to which the pelvic organs are 
subjected; especially lesions of circulation, excessive coition, labor, 
and gonorrlioea affect the peringeum more than the oi^ns higher up. 

In estimating the effects of loss of function, we should steadily bear 
in mind that diseases and accidents affecting the perinseum simulta- 
neously affect the organs associated with it and dei>endent upon it for 
support. While, therefore, we say that ruptured perinseum prevents 
complete involution of the uterus, we ought to remember that the 
two were simultaneously and equally subjected to the morbid effects 
produced by protracted or disastrous labor. The interdependence of 
the pelvic organs is such that I have no doubt but that subinvolution 
of the uterus and vagina sometimes keeps up a state of hyperaemia 
that prevents a ready repair of the damages done the perinseum. We 
know that rupture of the perinseum does not always arrest its involu- 
tion, and it is only when associated with disease of the pelvic organs 
that incK>nvenience arises from a small rupture, and in fact, extensive 
ruptures are not always a source of suffering. 

These considerations have a very important bearing upon the treat- 



RUPTURE OF THE PERINEUM. 29 

ment of a deficient perinseum, and often the best course to pursue to 
secure success in our treatment is to cure the associated disease first. 

A large uterus in a state of prolapse, or a hypertrophied and ex- 
tended vagina, if not properly treated before the operation will fre- 
quently undo an otherwise successful perinseorrhaphy. 

In reading the reports of uterine surgeons this fact will not unfre- 
quently show itself. In calling attention to the above considerations 
I do not desire to detract from the importance of a surgical opera- 
tion when the perinseum has been impaired by laceration, but I wish 
to apprise the student of the fact that when an operation is clearly 
necessary, like all other important surgical operations, it requires 
preparatory treatment to insure success. 

Rupture of the Perinceum. 

The perinseum and labia majora are liable to be torn during severe 
labor. A number of causes may, under certain circumstances, lead 
to these accidents. A straight sacrum, by allowing the head to 
emerge from the pelvis farther back than usual, although not a fre- 
quent, is an occasional cause. Rigidity of the perinseum, or undi- 
latable state of the external organs, a condition frequently found in 
aged primipara and occasionally in other patients, is also a cause. A 
large and unusually ossified head, malposition of the head when the 
occiput emerges too much posteriorly, and a too narrow arch to the 
pubis, may also act as causes of rupture. 

The perinseum may be, and doubtless is, not unfrequently ru23tured 
by the unskilful use of the forceps : First, by not making the proper 
spiral change in the position of the head so as to bring the occiput 
under the arch of the symphysis; or, secondly, by not causing this 
part to keep close to the symphysis, by raising the handles at the 
proper time, and to a sufficient extent; or, thirdly, by elevating the 
handles of the forceps too much, the points of the blade may be 
brought in forcible contact with the perinseum, and thus, added to 
the great distension, cause rupture; fourthly, the forceps may be 
allowed to slip off the head under powerful traction. Mere slipping 
of the forceps, when the points of the blades pass behind the head, 
and become detached entirely, and the convexity of them is not in- 
creased, will not generally produce this effect. When this is the 
manner of missing the hold of the instrument, the blades will be 
pressed close together, and pass through the parts without great disten- 
sion. But if, instead of this mode, the blades spring so that the 
points are made to pass out over the largest part of the head, and 
thus widely separate the blades, the convexity becomes so great as to 



30 RUPTURE OF THE PERINEUM. 

distend the parts enormously, and thus split through thefourchette first, 
and then the perinseum, and finally, in some instances, the sphincters. 

The injudicious use of ergot, by expelling the head so rapidly that 
the parts have not time to dilate, in some cases is undoubtedly the 
cause of ruptured perinteum. 

The head is not always the part of the foetus by which the rupture 
is produced, for sometimes the passage of the shoulders, if they are 
large and delivered rapidly, lacerates this part very badly; and I 
knew one instance in which the rupture was caused by bringing down 
the knee, and another case of breech presentation where the elbow 
caused a complete laceration of the perinseum. 

The breach of substance, of course, differs very considerably. It 
generally begins at the fourchette and extends backward to a greater 
or less extent. Mr. Brown divides the accident into slight and grave. 
He regards those as slight which are not ruptured through the 
sphincter, and believes that when the sphincter is violated, and then 
only, need much importance be attached to the accident. The exter- 
nal sphincter is sometimes injured considerably, and the rupture stops 
short of its complete division, and at others both are torn through, 
and half an inch or more of the recto-vaginal septum also divided. 
I saw one instance in which the two sphincters were torn through, 
while the larger part of the substance of the peringeum in front of 
them was uninjured, the child having passed through the septum 
into the lower rectum, and through the anus, producing the above 
rupture. This case did well without any operation. The wound 
generally commences at the fourchette, and extends backward towards 
the anus, but occasionally it takes a direction to one side and passes 
outside the sphincter, leaving the anal opening untouched. At other 
times the rupture, commencing at the fourchette, is directed laterally 
outward, so as to separate to a greater or less extent one or both of 
the labia from the perinseum. 

Effects of Laceration. 
We must not underrate the importance of the slighter forms of 
this accident, for, reason as we may as to the means adapted to the 
support and maintenance of the uterus in its proper position, as the 
floor of the pelvis the perinseum serves an important part in sustain- 
ing that organ. When the perineal support is lost, the positions of 
all the pelvic viscera are likely to be disturbed in their relations one 
to the other. It is very rare to see, indeed I have never seen, the 
uterus, bladder, or rectum, protrude from the vaginal orifice when 
the perinseura retained its perfect integrity. On the contrary, one 



TREATMENT. 31 

or all of tliem, when other causes co-operate, may be comparatively 
easily displaced after the main portion of the perineal substance is 
lost. It will only be necessary to remember that the perinseum being 
in the virgin triangular, the base at the skin, and the apex looking 
up and backward into the cavity of the pelvis, and that the upper 
part, or apex, extends at least an inch, and reaches obliquely above 
the tuberosities of the ischium, and that farther behind is quite a 
depression, into which the uterus, bladder, and rectum, in a state of 
distension, are lodged, gravitating there in a direction with the supe- 
rior strait, to understand the great inconvenience of its loss. When 
the perinieum anterior to the sphincter is split, this muscle will draw 
the anus farther back, and thus destroy the pelvic pouch, leaving its 
contents to settle still lower down. I think that it is in this wise 
the most distressing protrusion of the vagina, bladder, rectum, and 
uterus, one or all of them, is permitted, if not caused. It is true 
that in all cases of loss of the perinseum, protrusion of these organs 
will not necessarily occur, but when extensive displacement of this 
kind is observed, it is almost always in connection with deficient 
perineal support. More serious and invariable are the consequences 
of the most extensive ruptures — the loss of the functions of the peri- 
nseum and sphincter both. Prolapse of the viscera and involuntary 
discharge of the contents of the rectum result. If the fseces are hard, 
the patient can generally manage to seek a proper place to perform 
defecation ; but if fluid, there is no warning until they flow upon the 
person. The mucous membrane of the vagina is generally irritated 
and inflamed, while the skin is chapped and excoriated from frequent 
contact with the fseces. 

Treatment. 
Prevention, always the best treatment when available, will vary 
with the cause of the rupture. When, in labor, the perineum is 
very rigid, and relaxes with difficulty, the patient should be placed 
under the influence of chloroform, which induces relaxation with more 
certainty, perhaps, than any other remedy. Minute nauseating doses 
of tartarized antimony, every half hour, is next in efficiency to chlo- 
roform. I would not consent to bleeding in such cases, unless there 
was evident approach to inflammation in the part, and in no case is 
tobacco to be thought of. In this condition of the perinasum, the 
irritability of the structures ought not to be increased by attempts to 
support it. The perinseum may be supported when greatly distended, 
and when its integrity is threatened by too great inclination of the 
presenting part backward. The object of the support, in cases where 



32 RUPTURE OF THE PERINEUM. 

it is deemed advisable, should be to keep the head as close to the 
pubic arch as possible, but not to retard its expulsion. Not much 
force is allowable for this purpose, or any other in relation to the 
perinseum. It is needless, after what has been said as to the manner 
in which this accident occurs from the use of the forceps and ergot, 
to indulge in special admonitions as to their use. 

Spontaneous Cure. 

Occasionally nature is capable of curing some of the worst forms 
of lacerated perinseum. The first bad case of ruptured perinseum I 
ever saw was completely cured by nature wdth very little aid from 
art. It was in the person of a large and very fleshy primipara forty 
years of ao^e. The rupture extended from the fourchette to the in- 
ternal sphincter inclusive. Our ideas as to the proper mode of treat- 
ing recent cases of this kind at that time were not so decidedly in 
favor of immediate operation as at present. The only treatment this 
patient had was confinement upon the side and coaptation of the parts 
bv flexino; the knees somewhat and binding them securelv too:ether. 

„ CI O * o 

An examination three months after confinement showed a complete 
restoration of the periusum. This case occurred in the hands of a 
midwife. 

A more remarkable case occurred in my own practice. The patient 
was a large muscular woman who enjoyed robust health. In her 
first confinement she suffered a rupture of the entire perinseum and 
sphincter and three-quarters of an inch of the recto-vaginal septum. 
With the perinseum in this condition she bore two children. 

The operation to restore the perinseum, according to Baker Brown's 
method, was performed six years after the occurrence of the accident. 
The rent in the septum and perinseum was perfectly closed, and the 
vaginal opening was restored to its primitive dimensions. One year 
after the operation pregnancy ensued for the fourth time. When 
labor begun I was sent for, and arrived in time to find the occiput, 
which was posterior, ploughing through the periucTum, and by the 
time the condition of things was recognized my work was completely 
demolished. The perin?euin was gone. 

I proposed an immediate operation, but no persuasion or entreaty 
would induce my patient to submit to it. She was confined to the side, 
the limbs secured, and opium administered to prevent the passage of 
faeces through the rectum. Her recovery was perfect, and she has had 
two children since without a rupture. These two patients were alike 
in being large and fat, with fleshy limbs, so that when lying on the 



THE IMMEDIATE OPERATION. 33 

side the parts were pressed firmly together. They both had very 
short labors, and the perinsei were torn without being braised by long 
contact with the head. 

A patient is now under my care for subinvolution, who was sent 
by a physician of the interior of this State. Rupture of the perinseum 
had occurred as the result of forceps delivery, and, according to the 
statement of the gentleman who referred the patient to me, was en- 
tirely through the sphincter It is now five months since the acci- 
dent, and there is only the cicatricial trace of it left. The fastidious- 
ness of the patient forbid an examination, but the doctor was so sure 
of the existence of the laceration that he sent her to me for an opera- 
tion. From mv knowledo;e of his intellio^ence, and the amount of 
obstetrical experience he has had, I believe his statement in reference 
to the case. The spontaneous closure of slight lacerations is in fact 
so common that many practitioners of great experience regard them 
as of but little importance. 

The Immediate Operation. 

The cases in which patients escape from subsequent evils directly 
referable to ruptured perinseum are very properly regarded by ad- 
vanced gynaecologists as exceptional. An array of names, that must 
have weight with the profession, is made up of those of Munde, Fal- 
len, Xoeggerath, Skein, Garrigues, Emmet, and Thomas, of New 
York; Jenks, of Chicago; Lyman, Richardson, and Renolds, of 
Boston; Albert II. Smith and William Goodell, of Philadelphia; 
and Howard and Wilson, of Baltimore. To these names might be 
added many others of great respectability who favor immediate opera- 
tion for restoring a ruptured perinseum. 

An accoucheur can hardly be considered as performing his whole 
duty to his parturient patient unless he ascertains what effect has been 
produced by labor upon the perinaeum, and if there is rupture of even 
a moderate character take^ome efficient measures to restore its integrity 
at once. Most Avriters upon the subject recommend sutures of silk, 
catgut, or silver, applied as soon after delivery as possible. Any one 
of these substances will answer the purpose, but I think silver wire is 
the best. It will not generally be necessary to give an anaesthetic, 
as the sensibility of the parts is exhausted by the great pressure and 
distension to which they have been subjected. The application of 
the stitches should be made carefully and deep enough to include the 
whole of the cleft substance. Dr. Garrigues, in an excellent article 

3 




34 RUPTURE OF THE PERINEUM. 

in the April number, 1880, of the Ameriean Journal of Obstetrics, 
recommends the serre-jine as being sufficient in most cases of recent 
rupture. Dr. Garrigues tells us that they were invented 
Fig. 4. and introduced by Vidal de Cassis, of Paris, in 1849 

(Fig. 4). After an operation, or the use of the serre- 
jine^ the perinaeum will not always unite by first inten- 
tion; it so frequently does, however, as to encourage 
the effort. 

The operation inflicts so little pain that occasional 
failures should not deter us from the trial. Cases in 
which there has been protracted pressure and conse- 
quent bruising of the perinaeum will be more likely to 
fail than those in which the fcetus has been expelled 
with great precipitation. When the operation to heal a moderate 
laceration has failed, or the case does not come under observation 
until cicatrization has begun, the immediate operation is not advisable. 
If we do not perform the immediate operation for the first four or 
five days after confinement, the patient must be confined to her side, 
and it would be better, also, to surround the limbs at the knees with 
a roller, or bandage, to keep them constantly in contact. By lying 
on the side with the limbs close together, the parts are kept in 
almost perfect contact, and the lochial discharges flow out anterior to 
the wound. These two circumstances are essential to a cure. A 
diligent observance of the position on the side for a number of days, 
and a close proximity of the knees, is apt to result in adhesion of a 
part of the wound by the first intention, and much more of it by 
granulation. After the lapse of eight or ten days, the parts ought to 
be ins|)ected, and a healthy state of granulations encouraged by clean- 
liness, good diet, and, if need be, by a stimulating application of 
tinct. cantharides every four or five days. After the opportunity for 
treating such cases in their recent condition is past, and prolapse of 
the bladder, rectum, uterus, or vagina, renders interference necessary, 
the operative procedure is so similar to that necessary for the worst 
cases, that I will consider them in this respect together, and point 
out the difference as I proceed. 

A patient, to undergo this operation and be cured by it, must be in 
good general health. If she is not so, the operation ought to be de- 
layed until proper means can be used to effect it. A firm, plastic 
state of tlie solids, without unusual tendency to suppuration, will 
be the most favorable condition. Patients coming from the country 
wiJl do better to have the operation performed at once, and it is 



PERINEIORRHAPHY. 35 

better, if practicable, to send our town patients into the country 
for a month or more. Thirty-six hours before tlie operation is to 
be performed we must administer an efficient but not drastic laxa- 
tive; castor oil or rhubarb will do very well. The patient should 
be placed in the lithotomy position before a strong light. If an 
anaesthetic is administered, — and it will very much facilitate the 
management of the patient, — it may be given at this stage of the pro- 
ceeding. One assistant is placed at each side of the patient to steady 
the knees and hold the legs, while another assists in the use of instru- 
ments. The instruments necessary are a scalpel, a blunt-pointed 
bistoury, a pair of scissors, three large curved needles, or one large 
curved needle mounted upon a handle, tenaculum, dressing forceps, 
needle-holder, and wire-twister, and plenty of silver wire. Sponges, 
warm and cold water, of course, must be at hand. The surgeon seats 
himself in front of the patient wnthin easy reach. He commences by 
removing the hair from all the parts on which he is to operate. After 
which the edges of the cleft part are to be thoroughly denuded with 
knife or scissors. The cicatricial tissue should be all removed 
smoothly and evenly on both sides and up to and along the front 
surface of the septum. No part of the mucous membrane or super- 
ficial tissue of any kind should be left, as it will inevitably prevent 
union. 

Professor Edward W. Jenks, of the Chicago Medical College,* de- 
scribes his very ingenious method of denuding the parts in cases where 
the sphincter is not entirely torn through. He says : 

''I begin by nicking with scissors the anterior margin of the surface 
to be denuded, at the juncture of integument and mucous membrane; 
next, I introduce two fingers of the left hand into the rectum, while as- 
sistants hold the labia apart, it being important that they are held uni- 
formly tense. I use scissors slightly curved and sharp-pointed (Fig. 5) 

Fig. 5. 

m — m 




to denude the mucous membrane. I use neither tenacula nor tissue-for- 
ceps, but, with the parts tense, snip a hole in the mucous membrane in 
the median line, close to the integument, and then inserting the scissors 

* Op. cit. 



36 



RUPTURE OF THE PERINEUM. 



Fig. 6. 



with a cutting motion into the small hole made, I continue to dissect the 
mucous membrane away from the subjacent tissues without removing 
the scissors, first going up the septum as far as is desired, and then later- 
ally, first on one side, and then on the other, without removing the 
scissors or once bringing their points out from beneath the mucous 
membrane, as shown in Fig. 6. 

" Sometimes, instead of beginning 
my dissection at the median line, I 
begin at the nick on the left labium 
majus, running the points of the 
scissors beneath the mucous mem- 
brane, and dissecting it away from 
the subjacent tissues back on the 
left lip, then up the recto-vaginal 
septum as far as I deem it neces- 
sary, and from thenceforward on the 
right lip to a point opposite from 
which I started (marked by the 
nick), without allowing the scissors 
to come out from beneath the mem- 
brane, unless they are accidentally 
turned out by cicatricial tissue. Then 
with blunt-pointed scissors cut away 
the dissected flaps. The bared sur- 
face thus exposed is much the shape 
of a right-angled triangle, with the 
base directed outward, or it has been compared in shape to a butterfly, 
with wings spread and tail directed upward. 

" The advantages of this mode of denuding are : (a) the rapidity with 
which it can be done ; (6) the absence of haemorrhage in the vagina, as 
no blood escapes except at the locality where the scissors enter beneath 
the mucous membrane ; (c) the ability by which the operator can make 
complete denudation, as the discoloration between the membrane marks 
the route the scissors have taken. Several of my brother gynaecologists 
have tried this method of denuding, and are highly pleased with it. 
Among them is my friend Dr. Albert H. Smith, of Philadelphia, who, 
thinking he could better denude with a knife than scissors, had one made, 
which he found after several trials to be a very satisfactory instrument, 
by which he can denude much more rapidly, and yet on the same prin- 
ciple as with scissors. The knife (Fig. 7) has a dart-shaped thin blade 
with double-cutting edges. The patient, when the knife is used, is put 
in the same position, and with the same degree of tension of the parts as 
for the scissors; the knife is inserted beneath the mucous membrane in 
the median line, at its juncture with the integument, and from thence 




PERINEIORRHAPHY. 



37 



the submucous incisiou is made on one side, then 'upon the other, then 
up the septum the required distance, after which the flaps are cut away 
with blunt-pointed scissors. I have, up to the present time, used the 
knife devised by Dr. Smith only three times, and although, as a rule, 
having preference for the scissors over the knife in all plastic operations, 

Fig. 7. 



I have been delighted with the rapidity and ease by which I have been 
able to operate with the knife which he kindly sent to me." 

In complete laceration, where the septum is involved to any extent, 
the edges of the rent should be denuded and closed by silver sutures 
first, and the perineal sutures placed afterwards. 

The object of the perineal sutures should be to bring the ends of 
the torn sphincter together. If we use the long curved needle, it 




should be threaded with silk, and the point entered on the left side 
as far back as the posterior border of the anus, and passed forward 
and inward as high as the septum, including the lower edge of it, and 
then brought out on the right side, including the sphincter, in the 



38 KUPTURE OF THE PERINEUM. 

same manner as on tlie left. The silver wire is then attached to the 
thread and bronght through. The next suture is to be introduced 
exactly as the first, but about one-quarter of an inch further for- 
ward. These two sutures are intended to bring the ends of the 
sphincter muscles together. They generally do this quite effectually. 
Dr. Emmet was the first to insist upon this method of bringing the 
ends of this muscle in coaptation. Three or four more sutures are 
introduced, the third one deep enough to include the septum, aud 
the others of a depth sufficient to give solidity of surface. 

After placing the wires and being assured that their position is such 
as to secure perfect coaptation they may be twisted, beginning with 
tho^e behind, until the wound is accurately closed. If it has been 
iiece-ssary to close the septum, the wires should be left long enough 
to project beyond the vulva, to facilitate their removal. If the rup- 
ture does not involve the sphincter, the posterior suture is introduced 
anterior to the sphincter, but in such a manner as to draw forward 
the posterior angle of the wound and deep enough to include the 
septum. The other sutures may be placed as in the case of complete 
rupture. 

If there is rectocele in connection with the laceration, the anterior 
wall of the septum should be largely denuded, and the perineal 
sutures made to include a sufficiency of the redundant vagina to do 
away with the protrusion. 

As the silver wires do not cause ulceration and suppuration, like 
the hemp or silk sutures did when they were in use, it will generally 
not be necessary to remove them so soon. Unless the tissues included 
are somewhat strangulated, the sutures ought to remain nine or ten 
days, but if any tendency to ulceration shows itself, they must be re- 
moved early — five or six days. 

When the operation is complete, a rectal tube should be introduced 
and kept in the rectum for the first six days to permit the discharge 
of gas. If this precaution is not observed, the intestines may be so 
distended as to prevent union at the lower edge of the septum. 

When the operation for restoration of the perinseum is performed 
immediately after the injury, it is done, in everything but denuda- 
tion, similarly to that just described. I think the silver wires, when 
they can be obtained, are better than any other material for sutures. 
Where much delay would be necessary, however, to procure the 
proper material, the surgeon may use a straight cambric needle armed 
with silk. This hi^t material, if carbolized or well waxed, will 
answer very well for sutures. The only instrument absolutelv neces- 



PERINEIORRHAPHY. 39 

sary in these recent cases, is tlie needle with tlie silk. Sometimes 
they are all we can get without important loss of time. 

It is advisable, I think, before, or immediately after the operation, 
to give the patient about two grains of opium, or its equivalent in 
some of its preparations, and continue it at intervals, to keep the 
bowels from moving and allay irritability and pain. The patient is 
to be placed on her side, and have the limbs secured by a bandage at 
the knees. The position may be carefully changed from one side to 
the otl>er, being always particular to keep the legs close together, and 
not to allow them to be used so as to contract the muscles at the 
pelvis. Every six hours, or oftener, the catheter is to be used to draw 
off the urine, lest it run into the wound and vitiate the inflamma- 
tion. Dr. R. Stanbury Sutton, in an unpublished letter to me, says 
" the catheter is not necessary in perineal operations. I let the woman 
pass her water over a bed-pan, and then let the nurse wash out the 
vagina with a quart of hot water slightly carbolized. The wound 
should be kept covered w^ith pledgets of lint saturated with simple 
cerate or cold water." If suppuration occurs we cannot be too care- 
ful about cleanliness. Plenty of clean tepid or cold water must be 
injected into the vagina and rectum two or three times a day, while 
the external parts are sponged and cleansed as often. The young 
operator need not be discouraged if, upon examination, the wound is 
not all closed by adhesive inflammation. My experience is that this 
immediate and perfect closure does not usually take place, but that 
much of the deepseated portion is left to be filled by granulations, 
and it is sometimes several weeks before this is accomplished. The 
skin and integuments generally unite by the first intention, and when 
this is the case, there is not much danger of failure, provided we 
keep up a granulating surface all over the unhealed portion of the 
wound, and observe perfect cleanliness. At the end of twelve days 
some laxative will be necessary if the bowels have not been moved. 
The diet and medicine of the patient while in bed, after the opera- 
tion, cannot be the same in all cases, and are to be governed wholly 
by the state of the system; it will be better, I think, to err in favor 
of good supporting diet, stimulants, and tonics, rather than risk im- 
pairing the general health by abstemiousness. Adhesive inflamma- 
tion is promoted by a high state of physical health, and suppuration 
by a low condition of it, and aside from imperfection of the operator's 
proceedings, we have most to fear from early, copious, and persistent 
suppuration. 



CHAPTEE III. 

DISEASES OF THE VULVA. 

Condylomata of the Vulva. 

WaPvTY excrescences in great variety make the vulva the seat of 
tbeir growth. Thev are often flat, smooth elevations, small usually, 
but sometimes as large as filberts, isolated or congregated. Some- 
times they are sparsely scattered over the cutaneous surface of the 
labia, the mucous covering of the vulva, but not unfrequently they 
are thickly crowded together, with deep fissures between them and 
excoriations on their surfaces, that give origin to acrid sauious dis- 
charges, which excoriate the neighboring skin and soil the linen. 
The smell from this sauious discharge is sometimes very offensive. 
These excrescences are not always smooth and rounded even when 
isolated, but occasionally are rough and ragged, and in a few in- 
stances those springing from the margin of the vagina are arborescent, 
slender, and from half an inch to an inch in length. We again find 
tliem yellow, flat, and fragile. In most instances these growths are 
confined to the vulva and labia, but sometimes they cover a large 
part, if not the whole of the mucous membrane of the vagina and 
cervix uteri. I saw a case quite recently in which arborescent ex- 
crescences — many of which were three-fourths of an inch in length — 
sprang from the whole of the vaginal mucous membrane. This patient 
was pregnant by a syphilitic husband. 

The cause of these growths appears to be the syphilitic taint. So 
far as I now remember all observers agree that syphilis is the onlv 
cause of them. 

Treatment. 

We may very properly trust the alterative course calculated to 
remove the syphilisni under which our patient is laboring for the 
relief of the milder forms of these excrescences, and we should not 
fail to institute alterative treatment for even the more harassing va- 
rieties; but in many cases we shall relieve the patient more readilv 
by removing a part or the whole of the larger growths with scissors, 
and afterwards dressing the wounded surfaces with mercurial oint- 
ment. 



INFLAMMATIONS. 41 

Erythematous, papular, vesicular, and pustular inflammations of the 
vulva are not unfrequently observed, as are also squamous diseases. 
They resemble the same form of disease in other muco-cutaneous cavi- 
ties and the skin, and hence will not here claim a separate description. 
A disease somewhat more distinctive, however, and yet resembling a 
disease of the mouth, is known as purulent vulvitis. This affection is 
characterized by severe inflammation of the mucous membrane of the 
vulva, attended with minute points of ulceration, numbering from 
one to two dozen. The ulcers are small, an eighth of an inch in 
diameter, slightly excavated, and almost always covered with pus. 
The vulva is intensely red, and bathed in. pus and mucus. The in- 
flammation sometimes extends, into the vagina and causes a copious 
flow of pus and mucus from that cavity. Not unfrequently the 
labia are very much swollen, and occasionally the deeper tissues are 
involved in phlegmonous inflammation. This form of inflammation 
is not unfrequently, in its early stages, attended with considerable 
febrile excitement. To a superficial observer it strongly resembles 
gonorrhoea, from the swollen labia, burning pain, copious muco- 
purulent discharge, and the difficult and painful micturition. Its 
occasional sudden and unexpected development adds to this similitude, 
and legal proceedings have been instituted against parties supposed 
to have been instrumental in imparting the disease to little girls. It 
occurs in children generally from two to ten or twelve years of age, 
and probably results from want of cleanliness, heat, and local irri- 
tants accidentally applied. If allowed to pursue its course undis- 
turbed by treatment, other than cleanliness, it will generally subside 
spontaneously in two or three weeks, or in the course of that time 
become very much subdued, and run into chronic inflammation 
without ulceration. This last is often extended into adolescence, and, 
as vaginitis, gives origin to the leucorrhoea of girlhood, and finally 
to the endometritis of the woman. It sometimes attends upon a de- 
bilitated and scrofulous constitution, and is complicated with indiges- 
tion, constipation, and ascarides; but it is not likely originated, 
thouo^h it is ao^ojravated and fostered, bv these attendant circumstances. 

Treatment. 

The treatment is general and local. In the beginning, where the 
inflammation is high, it should be antiphlogistic and soothing. We 
mav administer a mercurial cathartic, and quicken its action by a 



42 DISEASES 0? THE VULVA. 

saline laxative, and after the bowels have been thoroughly moved, 
nitrate of potassa may be given internally, every three or four hours, 
in doses to suit the age of the patient. The parts should be frequently 
bathed or fomented with a decoction of poppy-heads, or with the 
watery extract of opium. In the course of four or five days the acute 
symptoms will begin to subside, when, in addition to attention to the 
bowels, we may administer an acid solution of quinine internally, 
and begin the use of astringents locally. A solution of tannin, sul- 
phate of zinc, acetate of lead, or other such astringent, weak at first, 
and afterwards increased in strength, may be applied freely to the 
parts four or five times a day. These remedies will generally remove 
the inflammation in a reasonable time. The astringent should be 
increased in strength to a sufficient degree for the purpose. If those 
mentioned are not strong enough, the chloride of zinc, sulphate of 
copper, or even nitrate of silver, may be very properly resorted to. 
Should the inflammation extend into the vagina, the astringent may 
be injected into that cavity by means of a small hard-rubber syringe. 
We ought to be careful to use a very small syringe, and not to introduce 
it too far. The nurse should be carefully instructed in this kind of 
application. I feel impelled to insist upon the complete removal of 
the inflammation as early as it can reasonably be done, believing that 
if it continues until puberty, the inflammation extends into the body 
of the developing uterus, and entails a very distressing train of suffer- 
ing upon the patient, that might have been avoided by an early and 
complete cure of the vaginitis. I am persuaded that too much im- 
portance cannot be attached to these views. 

Follicular Vulvitis. 

Inflammation of the vulva, instead of affecting the mucous mem- 
brane, as in the purulent form, is sometimes confined to the follicles 
and glands of the vulva. In this form of the disease minute papil- 
lary elevations on the mucous surface of the labia majora, the nym- 
phse, the prepuce of the clitoris, and elsewhere in the orifice of the 
vagina are first observed. These increase in size and become red, 
while the intervening mucous membrane is often very much inflamed. 
In many instances a number of these elevations become pustules, 
their bases hardened, red, and very tender. Oftener there is only a 
copious flow of mucus stained with pus-corpuscles from the follicles. 
The acute form will generally run its course and subside in a few 
weeks, sometimes in from ten to twenty days. But follicular vulv- 



PRURITUS PUDENDI. 43 

iris occasionally becomes chronic, and then is exceedingly obstinate 
and difficult of cure. 

Causes. 

AVant of cleanliness, vaginitis, pregnancy, and malignant affec- 
tions of the vagina and uterus are the most frequent causes. 

Treaiment. 

Rest in the recumbent posture, alterative and saline cathartics, 
cleanliness, first emollient poultices, and afterwards astringent washes 
and applications. If the patient is debilitated, the bitter tonics, quinine 
especially, will be found useful. The subjects of this form of vulv- 
itis generally require supporting and tonic treatment. When the 
secretions are oflPensive, carbolized glycerin should be freely applied, 
two or three times a day. 

When it is chronic, there will be necessity for the use of stimu- 
lants so strong as to modify the inflamaiatiou. Xitrate of silver in 
substance applied once in seven or eight days to the whole of the in- 
flamed surface will sometimes cause the disease to yield. In con- 
nection with this glycerin, with tannic acid dissolved in it, or im- 
pregnated with creasote, may be used between times. 

Alteratives are often found to be very beneficial. Iodide of po- 
tassium, sarsaparilla, stillingia, and, in plethoric patients, mercury 
are the ones on which most reliance may be placed. 

Dr. Thomas speaks of having made a cure by " dissecting off the 
whole mucous membrane lining the vulva.'' 

Pruritus Pudendi. 

A very annoying and often obstinate affection of the genital or- 
gans is an inordinate itching of the vulva. The itching returns in 
paroxysms. The patient will sometimes be free from it except when 
standing by a warm fire, or becoming heated by exercise, passion, 
etc. Or she may be affected only at or near the menstrual period. 
Again, the paroxysms return without any apparent reason. The 
sensation sometimes is that of a burning glow, attended with an irre- 
sistible desire to rub or scratch the parts, a desire which the most 
delicate sense of propriety cannot always keep within due bounds. 
At other times the sensation is such as might be produced by the 
crawling of pediculi, and the patient is assured that thousands of 
these insects are moving upon her person, and will be convinced 



44 DISEASES OF THE VULVA. 

to the contrary only by inspection. This sense of formication, al- 
thougli very disagreeable, is a slight inconvenience compared to the 
sufferings of the other variety. 

The former variety is almost always attended with inflammation 
of the mucous membrane of the vulva. The accompanying inflam- 
mation may be simply erythematous, papular, or vesicular. Dr. 
Dewees describes a variety of vesicular inflammation resembling 
aphtha, attended with pruritus. I am sure that the papulae or ves- 
iculse are neither of them always present in very distressing cases of 
this affection, although I have not seen it when the parts were not 
in some way inflamed. It may be observed that, in the formication 
variety of pruritus, the itching is generally mostly, if not wholly, 
confined to the cutaneous surface of the labia. It will be inferred 
that I consider pruritus but a symptom of several diseased condi- 
tions generally of the genital organs, but sometimes it undoubtedly 
may be caused by the state of the intestinal tube, particularly the 
rectum, or by some other remote condition. An intelligent scrutiny 
of the cases as they arise will most frequently result in the discovery 
of the originating condition. It is often an obstinate affection, last- 
ing for weeks, months, and even years, in bad cases, but more fre- 
quently it is amenable to treatment, and a judicious course will be 
rewarded by success. 

Treatment. 

The first thing to be done is to remove the cause, when practicable. 
In order to do this, the abdominal organs will require attention. 
The sluggish secretions and bowels must be corrected by alteratives 
and laxatives. A mercurial, say five grains of blue pill, may be given 
at night, to be followed in the morning by a saline laxative, sufficient 
to cause one or two stools. This may be repeated at intervals of 
from one to four days, until the object is gained. Meantime, if the 
stomach is weak and digestion imperfect, the bitter infusions, with 
alkalies or acids, as the condition may require, will be demanded; 
and should the patient be anaemic, iron may be given. Sometimes 
the patient will be plethoric, when the alteratives, with spare diet, 
will do better. With the above treatment, if the health be faulty, 
or without, if this is not the case, we will generally be obliged to 
resort to local remedies. AmX first of all is cleanliness. The parts, 
externally and internally, must be subjected to thorough and fre- 
quently repeated ablutions. The syringe may and should be brought 
into use for this purpose from three to a dozen times a day. The 
water used for ablutions may be impregnated with sal soda very ap- 



PRURITUS PUDENDI. 45 

proprlately, or some fine toilet soap. I have found much advantage, 
when there was no eruptive accompaniment, from two drachms of 
the tincture of the chloride of iron in a quart of water, three or four 
times a day. This is especially useful when there is leucorrhoea, and 
a congested, dark appearance of the raucous membrane. When there 
is a vesicular eruption, the recommendation of Dr. Dewees, to sprinkle 
the parts with powdered borax, and keep them exposed as much as 
possible to the air, will be of great service. Professor Simpson uses 
chloroform, in the forms of vapor, liniment, or ointment, with good 
effect. The infusion of tobacco, applied freely, two or three times a 
day, is recommended by the same author. When the mucous mem- 
brane is much inflamed, a solution of hydrocyanic acid, ten drops to 
the ounce of water, often gives great relief. A strong solution of 
tannin and aqueous extract of opium is also applicable to this class 
of cases. An excellent palliative is pure glycerin. It may be in- 
troduced into the vagina by saturating a plug of cotton with it, and 
passing it up through a glass speculum and allowing it to remain there 
for ten or twelve hours. We should take the precaution to attach a 
thread or cord to the cotton so that it may be readily removed. One 
of them introduced every twelve or twenty-four hours is often enough. 
We should also apply it between the labia in the same way. As 
explained by Dr. Sims, who first recommended its use, the glycerin 
induces copious serous depletion from the congested mucous mem- 
brane, thus relieving it. 

In cases of some duration I have often been enabled to produce a 
decidedly favorable change by applying the tincture of the chloride 
of iron in full strength with a brush once a day to all the mucous 
membrane of the vulva, and as far in the ostium vaginae as I could 
pass the hair-pencil. The first burning sensation is succeeded by 
great amelioration of the sufferings, and finally, in many cases, by a 
cure. When this fails, we may sometimes succeed by making a 
similar application of a solution of nitrate of silver in the strength 
of OSS. to o] of water. This last application should not be used 
oftener than once in two days. In the use of all these remedies we 
must not lose sight of the ablutions, nor fail to search for particular 
local causes, and try to remove them. As has been very judiciously 
remarked by Professor Simpson, we will find great advantage in al- 
ternating the use of appropriate remedies, instead of using the same 
kind all the time. The obstinacy of this affection will require great 
patience in many instances, as well as ingenuity in using remedies. 



46 DISEASES OF THE VULVA. 

Corroding Ulcer. 

I have met with a number of cases of corroding ulcer of the vulva 
in children, which have been the cause of great suffering and appre- 
hension. It occurs most frequently in children, but is occasionally 
met with in adults. There is in each case usually but one ulcer, and 
it is most commonly situated on the lesser labia at first, and spreads 
to surrounding parts. The ulcer is ragged and irregular, not much 
excavated, wMth a dark foul-smelling covering, and the discharge 
from it is sanious, fetid, and excoriating. It is not generally rapid 
in its progress, and sometimes lasts for months, creeping from one 
part to another until the anatomical features of the vulva are almost 
entirelv effaced. I have not met with this form of disease except in 
very debilitated, sallow, and badly nourished persons. The state of 
the system leading to this sort of ulceration I have thought to be 
more particularly the result of living in poorly ventilated houses, 
but coupled, also, with imperfect nourishment, or with nourishment 
of an improper character. 

It is generally obstinate, and yields but slowly to judicious treat- 
ment. 

We should endeavor, as one of the main objects, to correct the 
constitutional condition as speedily as possible. To this end the 
circumstances of the patient should be changed to the most favorable 
sort. Good ventilation at home, frequent and prolonged exposure 
to the fresh air, nourishing diet, of which animal food should be a 
large ingredient, and comfortable clothing, w^ith thorough cleanliness, 
are indispensable to success. The bowels should be kept in as correct 
a condition as possible by gentle laxatives. The digestion, which is 
always feeble, if not otherwise faulty, may be improved by the ad- 
ministration of infusion of cinchona, quassia, or colomba, with the 
mineral acids, the sulphuric being perhaps the best. The chlorinated 
tincture of iron is also an excellent oreneral remedv. The next thiuo- 
to be accomplished is to convert the ataxic, half-sloughing, and cor- 
roding chronic ulcer into an acute inflammatory one. This is done 
by profoundly stimulating it with the stronger caustics. The one 
which has seemed to me to be most successful is the caustic potassa. 
It should be applied to the whole surface by passing a stick, not very 
rapidly, all over it. After this burning we may dress the ulcer with 
calamine ointment twice a day. This will almost immediatelv im- 
prove the condition of the sore. Unless there is some considerable 
firmness around and beneath it, caused by the effusion of fibrin in 
the submucous substance, in thirty-six or forty-eight hours after the 



GANGRENOUS VULVITIS. 47 

application not much good will result from it, and it will be necessary 
to resort to it or some other in a few days. The strong nitric acid 
is also very useful. I have not tried the actual cautery, but should 
expect it to be very useful. We may often cure this ulcer by the 
weekly use of the solid nitrate of silver to it, dressing between times 
with lint saturated with black wash or calamine ointment. We ought 
not to be afraid of strong treatment, nor to continue it, in conjunc- 
tion with a highly roborant general course of exercise, diet, and 
m.edication. 

Gangrenous Vulvitis, or Noma. 

This is a very severe and generally fatal affection of the genital 
organs, occurring almost, if not wholly, among children. It may 
attack one or both sides simultaneously. In the few cases I have 
seen there appeared a bleb or blister on the inside of the mucous sur- 
face of the labium, which at the same time became enlarged, hard, 
tender, and painful. In a few hours the blister breaks, and from its 
side a not very abundant but acrid serum is discharged. At this 
time a peculiar odor is emitted from the parts. All around the ash- 
colored surface, which represents the place where the blister was de- 
veloped, the substance of the labium is very hard and much swollen. 
In two or four days the affected side is in a state of gangrene, the 
discharge is very much increased, the parts upon which it runs are 
excoriated and injflamed, and an intolerable stench is exhaled. I 
have not seen an instance in which the gangrenous parts were cast 
off, the patients having died beforehand. Generally, though not 
always, in the very beginning, the circulation and nervous system 
are very much disturbed. The pulse is quick and feeble, the patient 
nervously restless, or else stupid, the extremities cool, the body — 
particularly about the pelvis — hot, the tongue furred, generally brown, 
and the skin dingy and sallow. As the disease advances the pulse 
becomes still more rapid and weak, the extremities cold, the mind 
wandering, and the restlessness amounts to the frantic efforts of some 
sort of delusion. The tongue becomes dark brown or black, the teeth 
are covered with sordes, and in the end the patient sinks into profound 
collapse, and often coma, and dies. 

The disease runs its course sometimes in forty-eight hours, and 
again, in milder forms, it may last five or six days. The causes, 
although unknown, must undoubtedly be of a depressing nature, 
overwhelming the organism very rapidly. It occurs sporadically, 
when it is comparatively mild, and epidemically when severe. In 
this last state it is very rapidly fatal. 



48 DISEASES OF THE VULVA. 

The prognosis is very bad, as it is always, or pretty nearly always, 
fiital. The profession, so far as I am aware, has not decided whether 
the disease is a general one, and the affection of the genital organs an 
incident, or whether the local disease inaugurates the general symp- 
toms. The former is most likely the truthful interpretation of the 
phenomena. 

In such a disease there is little prospect of a cure by treatment; 
we should, nevertheless, institute a course clearly indicated by the 
symptoms and signs. The general treatment should be strongly 
stimulant, tonic, and supporting; quinia, brandy, tincture of can- 
tharides, and beef essence, as much as the patient can bear, should 
be administered. I do not think the strong caustic local treatment, 
generally advised, any better, if as good, as the charcoal and yeast 
poultices, chloride of lime, anodyne fomentations, and cleanliness. 
Much attention should be devoted to thorough ventilation, isolation 
of the patient, and the neutralization of the fetor by disinfectants. 

Urethral Excrescences. 

Caruncles of the urethra; vascular tumor at the orifice of the ure- 
thra : These names have been given to small tumors springing from 
the mucous membrane of the vulva, immediately round the urethral 
orifice, or from the lining of the urethra itself. They are generally 
solitary, but sometimes there are several. Sometimes they are sessile, 
and seem to be a hypertrophied fold of the mucous membrane of the 
orifice ; at others they are polypoid in their attachment. In size they 
vary from a pin's head to a small nut. They also vary in their appear- 
ance. As before remarked, they sometimes resemble in color, con- 
sistence, and polish the mucous membrane upon which they are 
planted; while in other cases they are quite red, almost scarlet, very 
soft, and easily broken. They differ in their anatomical properties 
quite as much as in appearance, seeming, in some instances, to have 
no more vessels and nerves than other portions of the neighboring 
tissue, while at others they are formed mostly of capillary bloodves- 
sels and loops of nerves. They are a morbid development of existing 
tissues instead of a growth of abnormal substance. These tumors are 
often observed, particularly the more dense and light-colored varie- 
ties, without giving origin to any symptom that would lead to their 
detection; on the other hand, in many instances, they often produce 
the most excruciating suffering. The kind of caruncle that has 
seemed to me to be the important one is the blood-red tumor pro- 



VASCULAR URETHRA. 40 

jecting from the mouth of the urethra and attached by a small neck. 
A few weeks since I met wnth one of these of crescentic shape, at- 
tached by a neck that arose from the concave margin, and had its 
other attachment inside the urethral orifice. It would not have 
weighed two grains, but it caused agonizing symptoms. It must not 
be supposed that all of the varieties will not occasionally cause great 
pain. The symptoms of their presence are almost always connected 
with the evacuation of the bladder and attempts to handle the part. 
The passage of urine causes the most excruciating suffering from pain 
and tenesmus, the patient often straining for several minutes after 
the complete discharge of the urine. The slightest touch, also, is the 
cause of great pain. The diagnosis cannot be clear without an ocular 
examination. If the parts are exposed to a good strong light, and 
the labia separated, the excrescence will be at once discovered, unless 
it be quite inside the urethra. If any doubts exist, we should intro- 
duce the finger into the vagina, and press the urethra forward. It 
is difficult to say, with truthfulness, what are the causes of these 
carunculas. My cases have been in patients obviously deficient in 
cleanliness. This seems to have been the case in that which came 
under Dr. AVest's observation. 

The treatment is simple, and consists in two main objects : 1st, the 
removal of them ; and, 2d, the production of a profound impression 
upon the point of origin. In fact, the tissues from which they spring 
should be destroyed to a slight depth. The first object may be most 
readily gained by snipping off with scissors; and the second by hold- 
ing caustic potassa, or the actual cautery, to the place until the nidus 
is destroyed. 

Vascular Urethra. 

Analogous to the caruncle is the vascular urethra. It gives rise 
to the same train of symptoms, though not so intensely distressing, 
and is very persistent. It occurs more frequently in patients near 
the climacteric period, although I have seen it in much younger per- 
sons. When the labia are separated, and the parts exposed to a good 
light, the urethra is seen to be patent, and the tissues around the 
orifice swollen and of deeper hue than usual. The mucous membrane 
of the urethra is of an intensely scarlet color, and, upon minute in- 
spection, the vessels may be seen enlarged ; it is very tender and sen- 
sitive to the touch, slight contact producing exquisite pain. There 
is great burning and sense of cutting when urine is voided, and all 
the symptoms, even the sympathetic nervous derangements, attendant 

4 



60 DISEASES OF THE VULVA. 

upon caruncle. This condition is not incipient caruncle, for there is 
no elevation, no protrusion, and the condition lasts for years withoat 
material change of substance. The treatment I have fouud most 
effective is strong nitric acid or caustic potassa appKed cautiously to 
the membrane inside the urethra. 

I have not tried the actual cautery, but believe it would be very 
effective. An application of the acid on a piece of lint moistened by 
it to the whole membrane in sight every ten days, for two or three 
times, generally is sufficient; sometimes once only is required. 

Hypertrophy of the Clitoris aiyi Nympha, 

It is very rare that we meet with hypertrophy of these oi^ans 
without morbid change in the tissues. There is either cystic devel- 
opment in their substance or degeneration of the membranous tissues. 
The two diseases that seem to contribute most frequently to this en- 
largement are syphilis and elephantiasis. 

Treatment. 
Removal by the thermocautery. 



CHAPTER IV. 

DISEASES OF THE BLADDEE. 

Paralysis of the Bladder. 

Paralysis of the female bladder is often an accompaniment of 
hemiplegia or paraplegia from cerebral or spinal affections, and be- 
comes a part of that more extensive affection. From my own obser- 
vation, however, I should say that in women, retention of urine in 
such cases is not so uniformly a troublesome symptom as it is in the 
paralysis of men. 

Women have paralysis of the bladder more frequently associated 
with hysteria, probably, than with cerebro-spinal disease, which con- 
dition, of course, is a part of the hysterical affection. 

Again, paralysis of the bladder may arise from reflex causes. I 
once knew an instance caused by the presence of a tapeworm. 

Still more frequent is the paralysis succeeding tedious, difficult, or 
instrumental labor, as the result of injury to the muscular structure 
of the bladder from long-continued direct pressure on the organ, or 
to the nerves supplying the bladder, by the use of instruments, or 
by long-continued pressure of the head. The inflammation succeed- 
ing labor may also affect the organ sufficiently to cause paralysis. 

Prognosis. 

Usually paralysis occurring as the result of labor is temporary and 
amenable to judicious treatment, if it does not spontaneously subside. 
Unfortunately, however, this is not 'ahvays so. I know of two in- 
stances that have resisted such management as could be devised for 
them by several able practitioners, one for twelve years and the other 
for seven years. Both of these patients use the catheter for themselves 
when there is an accumulation of urine. 

Symptoms. 

The main symptoms indicating paralysis of the urinary bladder 
are inability to pass urine and distension of the organ. The reten- 
tion is not always absolute ; in some instances the urine dribbles 
away constantly by drops, keeping the clothing wet. 



62 DISEASES OF THE BLADDER. 

The patient and inexperienced friends often believe that there is 
incontinence instead of retention, on account of this continued dis- 
charge. In other cases, however, wliere the paralysis is more pro- 
found, there is no discharge. The distension sometimes becomes 
very great, extending beyond the umbilicus half way to the ensi- 
form cartilage. 

Retention of the urine sometimes occurs as the effect of inflamma- 
tion of the urethra. This canal becomes so sensitive to the passage 
of that fluid through it, that the sphincter closes spasmodically when 
there is any attempt to urinate. 

Diagnosis. 

Paralysis of the bladder may be diagnosticated without much diffi- 
culty generally. The patient is conscious of inability to exert suffi- 
cient power to expel the urine, but often has no sensitiveness or pain 
upon voiding it. 

The hysterical form is usually attended with other symptoms of 
this affection, appears quickly and disappears as suddenly, while the 
urine is copious and clear. There is something in the manner of the 
patient which will often lead the inexperienced to think that she de- 
sires to have it drawn by the catheter. 

Cases resulting from injury at the time of labor may be traced to 
that event. 

Treatment 

Treatment for temporary relief will consist mainly in the use of the 
catheter. I think this instrument is generally used at too long in- 
tervals, especially in the form arising from injury during labor. I 
have often known cases of this kind to be neglected for twenty-four 
hours at a time. 

As a general rule, to pass the catheter every six hours is not too 
frequent. The muscular fibres " should not be stretched by a consid- 
erable and prolonged distension, as that will prevent them from re- 
covering their tone. And if the organ is kept well emptied, there 
is no danger of decomposition of the urine and the consequent irri- 
tation and inflammation of the mucous membrane. An intellio-ent 
nurse can be taught to perform catheterism very easily, and may be 
trusted to do so according to instructions as to time and other cir- 
cumstances. 

If the paralysis is connected with any general condition, as hys- 
teria, this latter should be attended to by general treatment. 

If the paralysis is general, the vesical affection will share in the 
general treatment of that affection. 



HEMORRHAGE FROM THE BLADDER. 



63 



The general health is usually impaired even when the paralysis is 
purely local in its origin, and often it is one of prostration. When 
this is the case, generous diet, exposure to and, when practicable, ex- 
ercise in the open air, with tonics and proper alteratives, will be in- 
dicated. Strychnia, quinine, and iron, separately or combined, will 
be useful remedies. The strychnia is particularly indicated as giving 
tone especially to muscular fibre and hence operating favorably on 
the debilitated tissue of the bladder. Phosphoric acid is also usually 
an excellent tonic in such cases. The bowels should be kept in a 
soluble condition by the gentlest of laxatives. 

"When there is evidence of inflammation of any of the pelvic vis- 
cera, we should remove it by the proper means before resorting to 
direct remedies to remove the paralysis. After all inflammation is 
removed, if there is any, we may employ electricity to stimulate the 
muscular fibres to contraction. An electro-magnetic current may be 
passed through the bladder in various directions, so as to stimulate 
all the fibres successively, applying the positive pole over the spine 
and across the posterior part of the loins, iliac and sacral regions, 
while the negative may be brought in contact with the symphysis, 
periuseam, and labia, and a catheter introduced into the urethra and 
passed slowly into the bladder. The whole of this faradization 
should not last more than five minutes at first, and should be re- 
peated once a day. After the patient has had three or four sittings, 
the force of the current and the duration may be gradually increased. 
It is sometimes very beneficial to pass the current from the anterior 
part of the abdomen into a metallic speculum in the vagina. I have seen 
many cases yield to this plan of treatment. A remedy that seems to 
have a very ready effect, and to which I think I may attribute a cure in 
some cases, is the secale cornutum. The fluid extract of ergot admin- 
istered in decided doses, once in a half hour for four or five doses, 
when the bladder is somewhat distended, often acts very promptly. 
A good way to administer the ergot is to induce decided ergotism, or 
give enough for that purpose every day and suspend the remedy in 
the intervals. I have been in the habit, also, of administering biborate 
of soda in doses of twenty grains four times a day with benefit. It 
is probable that all the substances that induce uterine contraction 
will influence the bladder sirailarlv. 



Hcemorrhage from the Bladder. 

A bloody discharge from the female bladder, not the result of or- 
ganic lesion of that viscus, is far from infrequent. It occurs more 



54 DISEASES OF THE BLADDER. 

frequently, judging from my own obser%'ation, about the time of the 
menstrual period and in persons whose flow is small in quantity. It 
is seldom, if ever, sufficiently copious to cause alarm, and the treat- 
ment of it may be trusted to the remedial measures required for the 
accompanying disease, whatever it may be. 

Hypercesthcsia of the Bladder and Urethra — Irritable Bladder and 

Urethra. 

An irritable condition of the bladder and urethra is a very com- 
mon occurrence among women, and is sometimes very distressing and 
persistent. The symptoms are frequent desire to urinate, with the 
discharge of but a small quantity at each time, vesical tenesmus, 
heat and weight, together \^ith a scalding sensation at the time of 
passing the water. This irritable condition may sometimes last, with 
varying severity, for weeks and even months without being attended 
with any considerable amount of ap^^arent disease in the parts. 

Causes. 
It is many times associated with inflammation and hypersesthesia 
of the vagina, with chronic metritis in some of its various form^, with 
displacements of the uterus, and irritation of the rectum from haBmor- 
rhoids, fissures, etc. But sometimes we meet with it when we can 
assign no cause whatever. 

Treatment. 

When it is possible to discover and remove the cause, that, of 
course, should be done. It will often subside under the treatment 
for the vaginitis that often attends it, or that made use of to remove 
ulceration and inflammation of the cervix uteri. So, also, when dis- 
placements are corrected, when we cannot trace it to any of these 
causes, the urine should be examined, and if found of strong acid re- 
action this condition should be corrected. This irritable condition 
of the bladder is quite common in women advanced in age, as the re- 
sult of a highly acid state of the urine, and may generally be re- 
lieved by the alkalies, of which the ]ireparations of potassa are prob- 
ably the best. The liquor potasste, in doses of from ten to fifteen 
drops, before and after eating, is often very efficacious. In young 
women of sedentary habits the vegetable acids will often improve 
the condition of the urine and render it less irritatincr. In either 
case the bitters may generally be given with advantage. There are 
some medicines that seem to have a peculiar influence upon the 
urinary organs, and may often be given in cases of this kind with 



CHRONIC INFLAMMATION OF THE BLADDER. 55 

great benefit. Among such are pareira brava, buchii, and uva ursi. 
The fluid extracts of these medicines are the most convenient forms 
for administration; but sometimes the extracts are not good, and 
hence I have been in the habit of relying more on the decoction than 
any other form. I often combine the buchu and uva ursi with, I 
think, excellent effect. AVhen the distress is considerable we may 
very properly use belladonna suppositories, per vaginam, at night. A 
half grain of the extract in cocoa butter, the same amount of sul- 
phate of morphia, will often quiet the patient and enable her to rest, 
when otherwise she would be annoyed by frequent desire to urinate. 
Vaginal injections of tepid or warm water often relieve the suffering, 
so do hip-baths and water compresses over the lower part of the ab- 
domen. 

ChroniG Inflammation of the Bladder. 

Although women are subject to acute cystitis, — probably not as 
often as men, — there is nothing in the course of the disease, or the 
treatment, that requires special consideration in a work of this kind. 
The chronic form, however, so far as I can judge from my own ob- 
servation, is more frequent in women than in men, and its course and 
treatment are both, in some respects, quite different, so that I am in- 
duced to give it distinct consideration here. It often complicates the 
various diseases of the uterus and vagina, and the displacement of 
these organs. It is also caused by foreign bodies in the bladder, as 
calculi, and substances introduced from without. 

Nature and Progress, 

In the beginning the inflammation in most cases is confined to the 
mucous membrane ; after awhile the muscular tissue becomes affected. 
In the early stage of the affection, while the inflammation is confined 
to the mucous membrane, the bladder empties itself completely but 
with great pain. As soon as the muscular structure is injured by the 
processes of inflammation, especially by the deposition of fibrin, the 
walls become thickened and uneven, contraction is imperfect, and 
hence the urine is retained, at first in small quantities and afterwards 
in larger; decomposition of this fluid takes place, the inflammation 
is aggravated, and ulceration follows in many instances; the patient 
sometimes dies from protracted suffering, or life is suddenly termi- 
nated by the ulceration perforating the wall entirely and causing 
fatal inflammation in the peritoneum or cellular tissue. Occasion- 
ally the inflammation spreads to the ureters, and through them to the 



56 DISEASES OF THE BLADDER. 

kidneys. The urethra may or may not be involved in the inflam- 
mation. Generally the cystic portion is more or less affected, and the 
ulceration in this direction will, in extremely rare instances, perforate 
the vesico- vaginal septum and thus cause fistula. The inflammation 
from foreign bodies contained in the bladder would be more likely 
to effect this condition than inflammation arising from any other 
cause. 

Symptoms. 

Dysuria, if not the most frequent symptom, is certainly one of the 
most frequent. The presence of even a small quantity of urine in 
contact with the inflamed mucous membrane irritates and causes a 
desire to evacuate it. There is also heat, a sense of weight or drag- 
ging in the loins, the region of the bladder, and in the pelvis, with a 
great amount of general suffering ; constipation, indigestion, some- 
times nausea, and various nervous symptoms being among the gen- 
eral symptoms. 

The urgency of the symptoms will depend, in a great measure, 
upon the amount of inflammation, but somewhat also on the consti- 
tutional peculiarities of the patient. The frequency of the discharge 
becomes very great, as there is constant pain and desire to urinate on 
account of the irritating character of the urine. With the urine is 
discharged a large amount of mucus, and as the disease advances 
pus and blood globules are found in the urinary sediment. The ap- 
pearance of the sediment is almost characteristic. It occupies the 
bottom of the vessel, is pellucid, tinged with yellow if there is pus 
in it, or red if it contains blood-corpuscles, and when poured out 
either comes in a jelly-like mass or in long strings of mucus that may 
be drawn out to great lengths. At the bottom of the sediment are 
usually found an abundance of the phosphatic salts. As the disease 
advances, the odor of the urine becomes highly ammoniacal and not 
unfrequently fetid. Generally the odor is quite unnatural. 



The diagnosis is not difficult. The sediment of the urine, under 
the microscope, will show the presence of pus-globules in grave cases, 
and sometimes blood-globules. When pressed upon above the pubis 
the bladder will be found tender. This tenderness will be more evi- 
dent upon introducing two fingers into the vagina and elevating the 
bladder upon them, while pressure is made above the pubis. The 
bladder may be thus included between the two hands. The tenacious 



CHRONIC INFLAMMATION OF THE BLADDER. 57 

ropy sediment, the pus and blood globules, especially the former, and 
the tenderness of the bladder upon bimanual pressure are the main 
diagnostic symptoms. 

Prognosis. 

Chronic inflammation of the bladder is an obstinate di'sease, and is 
very difficult of cure; yet it probably does not often prove fatal. 

Treatment. 

The complicating conditions — as the disease is associated with 
others in the majority of instances — should be attended to with great 
diligence. The pelvic viscera are so near each other that inflamma- 
tion seldom exists in one for a great length of time without spread- 
ing to others. I believe this affection is often the result of extension 
front the vagina or uterus, and in many instances it arises from 
pelvic peritonitis and cellulitis. Many of the remedies used for 
the cure of one of these affections will benefit the others also. The 
use of the hip-bath once or twice daily, copious w^arm-water injections 
as often, poultices, compresses, iodine ointment, vaginal suppositories, 
— of anodynes especially, — will all have the effect of relieving intra- 
pelvic hypersemia and hypersesthesia. Counter-irritants of a decided 
character may frequently be made of great service. One or two setons 
introduced just above Poupart's ligament, in one or both sides, are 
very effective means of making it. They may be controlled better 
than blisters or eruptive irritants. We have a number of articles in 
the materia medica that exert a curative influence by contact with 
the mucous membrane of the bladder. They are eliminated from the 
blood by the kidneys, and held in solution or suspension in the urine, 
thus becoming applied to the diseased surface. Probably chief among 
these is pareira brava. I think the best way to administer this is in 
decoction, although the fluid extract, when properly made, is a good 
form ; buchu, uva ursi, and juniper, are also very useful. I think 
more good, in most cases, results from the use of buchu and uva ursi 
together than from either alone. Iodide of potassium, permanganate of 
potash, and some other salts of this alkali, the acetates and nitrates 
for instance, exert an excellent alterative effect upon the mucous 
membrane of the bladder. The terebinthinates may be used with 
great advantage in the milder forms of this inflammation. Perhaps 
balsam copaiba is the most uniformly beneficial of this class of rem- 
edies. Cubebs may also be employed occasionally with good effect. 
The above treatment is applicable and often sufficient in the earlier 
stages and milder forms of chronic inflammation of the bladder ; but 



58 DISEASES OF THE BLADDER. 

after contraction of the organ is impaired by the extension of the 
inflammation to the muscnlar strncture, surgical treatment becomes 
indispensable to a successful issue. It is necessary that the acrid urine 
be completely removed from the bladder before it enters into chemi- 
cal decomposition, which it does very quickly. At the same time 
the direct application of medicine to the inner surface can and ought 
to be made, while alterative and tonic general treatment is instituted 
to overcome interstitial inflammation and remove the fibrinous de- 
posit. Often we may accomplish the processes of emptying the 
bladder and applying the medicinal agents by means of the double 
catheter. To insure the eflicacy of these measures the organ may be 
washed out by warm water thrown through the catheter by a David- 
son syringe, and after all the urine is washed out the medicinal solu- 
tion may be introduced, and allowed to remain until its action is accom- 
plished. When there is much pain a quarter or half grain of morphia 
once in twenty-four hours will secure immunity from suffering. We 
may combine with the morphia a solution of iodide of potassium, 
permanganate of potash, tannic acid, acetate of lead, or other astrin- 

FlG. 9. 



Skene's Double Perforated Catheter. 

gent; or we administer in the same way a small amount of an emul- 
sion of balsam copaiba. Nitrate of silver will also frequently cause 
a better condition of the inflamed surface. The ingenuity and ex- 
perience of the practitioner will generally suggest remedies of the 
above character best suited to the particular case. Due caution must 
be observed not to use the remedies in too concentrated strength until 
the tolerance of the inflamed surface is ascertained. These medica- 
tions should be applied once a day at first, and afterwards as often 
as may be required. It should be borne in mind that the raucous 
membrane of the bladder is very sensitive and that medicines are 
readily absorbed by it. In connection with this surgical treatment 
ergot and strychnia may be given to insure tone in the muscular 
structure. They ought not to be administered, however, until the 
activity of the inflammation has somewhat subsided. Dr. J. L. 
Papin, of St. Louis, has practiced a plan for relieving the irritable and 
inflamed condition of the bladder by dilating the urethra so as to 



CHRONIC INFLAMMATION OF THE BLADDER. 59 

paralyze the contractile fibres and leave the canal patulous, thus allow- 
ing the urine to pass out as fast as secreted, instead of permitting it 
to remain in the bladder to irritate it. The treatment is described in 
a paper written by Dr. M. Yarnall for the January (1872) number 
of the Medical Archives, published in that city. The operation is 
thus described : The urethra is dilated " with a long pair of dressing 
forceps to such an extent as to produce a temporary incontinence of 
urine, by rupturing a few of the fibres of the sphincter of the blad- 
der, and repeating the operation when necessary, at intervals of a 
week or more, until the patient is completely relieved." Twenty 
cases are mentioned as having been treated in this way, and the report 
is : " In nearly every instance the relief afforded is almost imme- 
diate ; but in the course of a few days the irritability of the bladder 
usually returns, when the operation has to be repeated, and, if neces- 
sary, again repeated until a cure is accomplished." In one case the 
operation was repeated five times, in some others three and four 
times. The experience of Dr. Papin is such that he does not fear 
incontinence of urine. " The operation being at first very painful, it 
will usually be found necessary in performing it the first time to place 
the patient under the influence of an anaesthetic ; but its subsequent 
performance being much less severe, as a rule the anaesthetic will not 
be necessary, unless the patient be of a very nervous temperament." 
This dilatation will much facilitate the use of medicated injections 
and preclude the need of a double catheter. 

This operation is very simple, and, according to the report of Dr. 
Yarnall, very efficacious. 

I have practiced dilatation of the urethra quite frequently with 
results not inferior to those here reported. 

I invariably use the finger in place of any other instrument. One 
of the dangers of dilatation of the urethra is laceration of the circu- 
lar fibres of that canal, and consequent incontinence of urine. I 
have not met with an instance of this kind, nor have I seen anv other 
serious consequences follow dilatation. The finger may be passed 
through so slowly that the fibres will stretch, and endowed as it is 
with a delicate sense of touch, it easily recognizes the unyielding 
tension which indicates care. In this it would be entirely prefera- 
ble to any kind of instrument. Compressed sponge or laminated 
tents dilate so slowlv and remain in contact with the canal so lon^ 
as to induce inflammation and softening of the muscular fibres, 
and instead of preparing the way for further safe dilatation would 
predispose to laceration. 



60 DISEASES OF THE BLADDER. 

Dr. Goodman, of Louisville, uses a catheter with a small bulb on 
the vesical extremity of it, with which he secures an empty state of 
the bladder. 

Dr. Sims's well-known practice of incising the vesico-vaginal 
septum has for its support the favorable report of its distinguished 
originator and Dr. Emmet, his successor in the Woman's Hospital 
of New York. The latter gentleman has written, and read before 
the Academy of Sciences of New York City, quite an elaborate 
paper advocating the propriety of making a fistula through which 
the urine will pass without accumulating in the bladder, and 
through which very effective medicinal application may be made 
to the inflamed surface. The patient may be placed in the position 
advised to operate for vesico-vaginal fistula, and the parts exposed 
by Sims's speculum. The surgeon may then pass a grooved director 
into the urethra with the groove toward the vaginal septum, and cut 
down upon the director until an opening is made large enough to 
answer the purpose. There is probably more danger of having the 
opening too small than of getting it too large, as the parts contract 
and have a strong tendency to close up before the cure is effected. 
The opening should be about an inch in length. With this free 
communication with the interior of the bladder the medication may 
be complete Tincture of iodine, a solution of nitrate of silver, and 
the various astringents may be applied through the artificial opening. 
The injections for washing out the bladder can be used with such 
freedom as will insure cleanliness. Dr. Emmet assures us that this 
method of treatment has been almost uniformly successful in his 
hands. The operation to cure the fistulous communication between 
the bladder and vagina is so well understood and so generally suc- 
cessful, that the surgeon will not dread the consequences of this plan 
as it would have been dreaded some years ago, and I need hardly say 
that the opening should not be closed until the inflammation is en- 
tirely cured. It often closes spontaneously. 

Stone in the Bladder. 
Vesical calculus in the female is of very rare occurrence, absolutely 
and relatively. Of all the cases of vesical calculus only about one in 
twenty is met with in the female sex. This may be accounted for by 
the size, straight form, and dilatability of the urethra, and consequent 
direct escape of small sanguineous and mucous accumulations, and even 
sandy concretions. Indeed, quite large stones are expelled through 
the urethral canal, making their way out, in some instances, in a few 
moments with acute suffering, while in others they are many hours 



STONE IN THE BLADDER. 61 

iu forcing a passage. It would seem that these hard substances are 
evacuated more readily during the state of pregnancy than at any 
other time; doubtless, because of the urethra partaking in the general 
increased dilatability of the genital organs which precedes labor. 

Si/m.2:>toms. 
There are probably no symptoms attendant upon stone in the 
bladder in woman but what are produced more frequently by other 
causes, hence they are quite unreliable, and can be taken only as 
suspicious instead of diagnostic evidence of its presence. They are 
great and persistent irritability of the bladder, severe pain after void- 
ing the urine, sudden cessation of the flow while there is yet a desire 
to urinate and evidently some fluid in the organ, enlargement or 
relaxation of the urethra, and incontinence of urine. The urine is 
also charged with mucus, pus, or blood, or all three of these in greater 
or less quantities. The symptoms will be more strongly marked if 
the calculus is rough and jagged in shape, and less so if the surface 
is smooth and even. All these symptoms are not present in any given 
case, but some of them are certain to be prominent and very distressing. 

Diagnosis. 
The only way to positively determine the diagnosis is by physical 
examination of the cavity of the bladder. This is done by means of 
the fingers and the sound. If two fingers be passed deeply into the 
vagina, as far as the cervix uteri, the most dependent part of the 
bladder may be pressed strongly up against the internal fiice of the 
pelvis, or lower portion of the anterior abdominal wall. If this latter 
be pressed w^ell down into the pelvis with the other hand, while the 
fingers are still in the vagina, careful manipulation will scarcely fail 
to distinguish a calculus of moderate size. When the bladder is full 
of water, if the calculus is large, it may be raised and its presence 
pretty conclusively determined by ballottement. The stone is felt, 
however, more distinctly througli the urethra by the sound, used the 
same as in the male. The operation may be facilitated by the fingers 
in the vaccina movino^ the stone around. The same difficulties in 
preventing or making difficult and perfect diagnosis are met with, as 
in the male, if the stone be encysted or adherent to the upper or 
anterior wall of the bladder; but if the instrument is sufficiently 
curved and moved about in various directions it will be detected, and 
its position and size ascertained with more precision and certainty 
than in the male. 



62 DISEASES OF THE BLADDER. 

Treatment. 

The only means of relief available is the entire removal of the 
calculus. This may be done by dilating the urethra, and extracting 
through it ; by litliotomy or lithotrity. All these operations are less 
hazardous in the female than in the male, in fact, we scarcely take 
the subject of danger to life into consideration in operating for stone 
on a woman ; but one very great inconvenience likely to follow dila- 
tation of the urethra and lithotomy is incontinence of urine, and the 
attention of recent o]3erators is turned mainly to the matter of avoid- 
ing this most distressing sequel. The preference is given by some 
surgeons to lithotomy, because they think this evil less frequent after 
it, while for the same reason others resort to dilatation of, and extrac- 
tion through, the urethra. Very few now practice lithotrity in the 
female, and this operation is looked upon as attended with more 
hazard than either of the others. It is astonishing with what facility 
the female urethra may be largely and rapidly dilated. I have seen 
it stretched so as to admit the index finger in ten minutes without 
violence to its integrity. Where the stone is not very large, not over 
half an inch in diameter, we may expect to succeed by dilatation with- 
out much damage if proper caution and gentleness are used. When 
the stone is much larger, and especially if it is rough, we should cut. 

The operation of dilatation is simple. It may be performed by 
the finger more readily and safely as directed in chronic inflamma- 
tion of the bladder. As soon as the finger can be made to enter 
freely the bladder, other fingers should be passed into the vagina and 
caused to press the stone forward so that its size, shape, consistence, 
and the character of the surface be ascertained. If there is a lono- 
diameter, the end must be directed to the urethral opening, and re- 
tained with as much security as may be until the forceps are intro- 
duced and the stone seized. Traction should be made in the direction 
of the urethra with the instrument, while with the fingers in the 
vagina the efibrts may be governed so as to keep up the right direction 
and steadiness, and also to push the stone into the urethra. Swaying 
the instrument in different directions, and performing slight rotation, 
the force used should be very gently applied and slowly increased, 
giving the parts time to stretch, and no more exerted than is just 
sufficient to accomplish the extraction. We should not be in a hurry, 
but take plenty of time; more damage is done by too great hurry 
than too great dilatation, I think. The parts are torn instead of 
being stretched. If the stone is too large to be removed in this way, 
we may perform lithotomy. 



FOREIGN BODIES. 63 

Dr. Sims has proposed and performed litliotomy throngli the vesico- 
vaginal septum. He exposes the parts as for operation for vesico- 
vaginal fistula, introduces a curved director through the urethra, and 
cuts into the bladder upon it until the opening is large enough to 
permit the stone to pass. The finger is then passed through the ar- 
tificial opening by which the forceps is guided, the stone seized and 
extracted through it. The wound is then closed with silver sutures, 
and the patient otherwise treated as for fistula. 

Foreign Bodies 

Are sometimes introduced into the bladder by accident or design. 
Lead-pencils, hairpins, quills, etc., are found in the bladders of hysteri- 
cal girls. They may be generally easily extracted by dilating the 
urethra, seizing the substance with strong forceps, and withdrawing 
them. Several instances are recorded of the open-barred pessaries of 
Dr. Hodge being removed from the bladder, where they had been 
introduced by mistake. The practitioner, starting one limb of the 
instrument into the urethra instead of the vagina, and afterwards 
manipulating in the ordinary way, would easily pass the whole into 
the bladder without observing any difference in the passage through 
the parts. Dr. H. R. Storer, of Boston, has now had three cases of 
this kind, and others have also met with them. I have seen but one 
instance of the accident, or rather mistake. In that case the instru- 
ment was introduced by an intelligent physician, who was sick and 
stupefied by opium. As he died a few days afterward there was no 
opportunity of hearing his account of the matter. The pessary re- 
mained in the bladder several months, during which time the patient 
was married and became pregnant. Three months after conception 
the instrument was discovered and removed without interrupting 
gestation. The removal was not attended with much difficulty. 
The urine was all drawn, and as the bladder emptied and contracted 
the pessary, coming down upon the anterior wall of the vagina, was 
distinctly felt, and its shape and size easily distinguished. The little 
finger was first pressed into the urethra until it passed into the bladder, 
then the index, by which the end of one of the branches of the in- 
strument was drawn to the vesical end of the urethra. The finger 
was then withdrawn, and Ricord's phimosis forceps introduced until 
in contact with the limb of the pessary. To facilitate the prehension 
of it by the forceps, the index finger of the left hand in the vagina 
held the pessary against the pubis. In this way it was not at all 



64 DISEASES OF THE BLADDER. 

difficult to fasten the forceps on the end of the limb lying in contact 
with the neck of the urethra, and to extract the whole instrument. 
This was done by first bringing the point of the branch seized upon 
out of the meatus, depressing it toward the perinseum until the angle 
at the junction with the cross-bar appeared, after which the changes 
were the same as removing from the vagina. This case was recorded 
by Dr. Buckley, of Freeport, Illinois, in the Medical Record. Es- 
sentially the same plan enabled Dr. H. R. Storer, of Boston, to re- 
lieve his patients. A foreign body that has been introduced through 
the urethra can, by this kind of manipulation, be removed through it. 

Inversion of the Bladder. 

In childhood the bladder sometimes becomes inverted and partially 
expelled through the urethra. Dr. John Croft, in ^'St. Bartholomew 
Hospital Heports/^ American P7'actitioner, gives the following methods 
of diagnosticating and treating inversion of the bladder : 

" A small, red. pyriform, vascular, elastic tumor, situated between the 
lahia below the clitoris, and in front of the vaginal orifice ; the urethra 
not distinguishable ; the ureters may be exposed, and perhaps distilling 
urine; a history of more or less incontinence previous to the appear- 
ance of the tumor : these symptoms should lead one to recognize an 
inversio vesicce, and to distinguish such an affection from a solid polypoid 
growth. Mr. Holmes has described a vaginal hernia in his work on 
Diseases of Children. In that malady the urethra can be found in front 
of the tumor, which has not the red vascular appearance of an inverted 
vesical membrane. The best mode of reduction seems to be by taxis, 
and the thumb and fingers the best compressors. They should be used 
gently. If the child struggle much, it would be better to employ chlo- 
roform." 

A properly constructed compress will retain the parts in position 
until the urethra attains its normal tone. 



CHAPTER V. 

AFFECTIONS OF THE VAGINA. 

Absence of the Vagina. 

"We observe absence of the vagina when the tissues and organs in 
near relations to it are in one of two conditions : First, when the 
rectum, bladder, and vagina are all absent and replaced by one great 
cavity, through which the urine and faeces are passed. This cavity 
is called by authors cloaca, being a common excretory canal for the 
urinary, genital, and alimentary organs. Sometimes the vagina is 
imperfectly formed, and the rectum perforates it posteriorly, while 
the urethra enters it anteriorly. Secondly, the vagina may be absent 
while the rectum and bladder are properly situated, perfect in their 
formation, and the anus and meatus urinarius both also occupying 
their normal places and performing their functions properly. In 
this last condition of the parts the vulval organs are generally all 
present; in one case the hymen was to be seen. In by far the most 
instances there is an absence of the uterus when the vagina is not 
found, but this is not always the case. I feel confident of having 
seen two cases in which the uterus and vulva were normal. 

Causes. 
Absence of the vagina is, of course, always a congenital condition. 

Diagnosis. 

In cases where there is a common cavity for the rectum and blad- 
der, we shall have no difficulty in ascertaining it by inspecting the 
parts with the eye and passing the probe into the rectum and bladder 
if necessary. The discharges, however, will generally enable us to 
decide without this last measure. When all the adjacent organs are 
normal, we are to distinguish between occlusion by an abnormal 
hymen, rudimentary vagina, and this condition. 

Physical examination alone will enable us to do this. We shall 
not often be called upon to determine the question of diagnosis until 
there is a collection of menstrual fluid in the cavity of the uterus, or 
the patient is married. 

5 



66 AFFECTIONS OF TEE VAGINA. 

When there is occlusion bv the hymen, with a collection of fluid 
in the vagina, the vulva will be occupied by a tumor formed of the 
pouting membrane, generally of a dark-purple color and hemispherical 
in shape, giving the sense of fluctuation when pressed upon at the time 
the hypogastric region is percussed. When the vagina is absent, there 
will be a tumor perceptible between the bladder and rectum, but no 
protrusion between the labia. The ordinary sign so often mentioned 
of a cordlike hardness extending from the vulva upward is of no use, 
as this is obscured by the globular mass between the rectum and blad- 
der. In one case recently under observation the uterus was absent, 
and the rectum and bladder seemed to be in immediate proximity. 

The treatment of absence of the vagina will be given in the treat- 
ment of atresia. 

Atresia Vagince. 

This condition arises very much more frequently from puerperal 
inflammation of the vaginal parietes than any other cause. But any- 
thing that produces inflammation enough to destroy the epithelium 
of the mucous membrane may cause atresia, as mechanical or chemi- 
cal agencies, scarlatina, measles, sy])hilis, etc. 

After extensive ulceration from these or other causes, if the denuded 
surfaces are allowed to remain in contact and at rest for a time, they 
contract adhesions, thus narrowing, or even at times completely clos- 
ing, the cavity. In atresia occurring as the effect of inflammation 
every variety may be observed. The vagina may be closed at the 
vulva and not above, the centre may be contracted and the upper 
and lower ends be of normal dimensions, or the adhesion may take 
place at the upper part, including or not the os uteri. In all these 
varieties, however, the parts not involved in the ulceration are but 
little affected. Atresia may also be a congenital defect in the organi- 
zation. Congenital atresia is more frequently caused by the forma- 
tion of a membrane across the cavity, closing it in some part, as the 
hymen occasionally closes the vulva, and which is often so low down 
as to be confounded with that membrane. Such a closure, however, 
is usually farther up the cavity, sometimes near the os uteri. Partial 
congenital atresia is sometimes represented by a very narrow canal, 
only large enough to admit a probe, and which seems a very im- 
perfect outlet for the menstrual discharge, and is so small as to pre- 
vent sexual intercourse. This form of atresia may be complete and 
^'the organ changed into a solid cord,'' extending in part or the whole 
of its length. 



ATRESIA VAGINAE. 67 

Diagnosis. 

Judging from my own observation we are more frequently called 
upon for a diagnosis in atresia after puberty than before. Previous 
to puberty the closure of the external opening to the vagina would 
be the only condition likely to lead to its discovery. The diagnosis 
in such cases is of little importance compared to what it becomes after 
adult age, as the defect does not interfere with the function of the 
organ. The failure in the appearance of the menses at the proper 
time in life, pain in the pelvic region, and enlargement of the abdo- 
men generally cause physical investigation. If it has originated in 
ulcerative inflammation, the retention of menstrual fluid, pain, and 
enlargement would soon excite suspicion ; or, if the patient is married, 
the husband would be likely to discover the unusual state of things. 
Practically a very large majority of the cases we meet with will be 
attended with an accumulation of fluid. The history of the case, the 
fluctuating tumor between the bladder and rectum, felt by the finger 
in this last cavity and the catheter in the first viscus, and the presence 
of some part of the vagina in a distinguishable condition will enable 
us to decide as to the nature of the difficulty. 

Prognosis. 

There are very few cases of acquired atresia which do not admit 
of more or les^ complete relief. Congenital atresia with membranous 
formation across the cavity is generally curable, and when the vaginal 
cavity is so contracted as to be nearly, but not entirely obliterated, 
we may hope for a cure, but when it is attended with defective de- 
velopment of the other genital organs we may expect much difficulty, 
even if a cure be practicable. 

Treatment of Atresia and Absence of the Vagina. 

The object of treatment is to overcome the obstruction to the dis- 
charges from the uterus by surgical means. The vagina is a viaduct 
for the uterine discharges. In this word, to be sure, is not expressed 
all the uses of that organ, but to make it an efficient channel for the 
menses is really almost the only reason for operations in the graver 
varieties-(5f vaginal atresia. We are not, therefore, justified in sub- 
mitting our patient to the dangerous operation of opening up the 
vaginal canal for any other purpose. In cases, therefore, in which 
the uterus is absent we are not justified in attempting to form an 
artificial vagina, or in any way endeavoring to perfect the organs for 



68 AFFECTIONS OF THE VAGINA. 

conjugal purposes merely. I have known but one attempt of this 
kind, and in that case no success attended the persevering and in- 
genious efforts of Dr. Brainard. The patient was a married woman, 
who said she assumed matrimonial relations without knowing that 
she was not like other women. The vagina terminated in a cul-de- 
sac about an inch in depth. Her husband complained of her inca- 
pacity to fulfil the duties of a wife. They visited Dr. Brainard for 
surgical aid, and he had the kindness to allow me to witness his 
operations. Although the artificial canal that resulted from his 
efforts was two inches in depth, it had a constant tendency to con- 
tract, and required the steady employment of a glass plug to keep it 
open. The husband was not satisfied and the law allowed him to 
separate from her. 

The occlusion should not be operated upon until the menstrual 
fluid fills up the uterus and distends the parts between its cavity and 
the vulva. Ordinarily, when the vagina is absent, the uterus is 
bound by areolar and fibrous tissues to its usual situation in the 
pelvis, and as distension occurs the lower portion of the organ ap- 
proaches very near the vulva,- — in two instances of absence of the 
vagina it was not more than an inch and a half from the vulva. In 
thus approaching the external organs it widely separates the bladder 
and rectum; pressing the former up behind the pubis, and the latter 
strongly into the hollow of the sacrum. 

This condition of things makes an operation for the opening of the 
vagina, or making an artificial canal, comparatively easy and safe. 
To attempt to reach the uterus of a girl before puberty has estab- 
lished the menses, by cutting up toward that organ from the vulva, 
is to undertake a task of very great difficulty and hazard, which, 
after the distension has brought about the changes above described, 
may be accomplished with great certainty and facility and much less 
risk. Much delay, permitting of great distension, should also be 
avoided, for Puesch tells us that in 258 cases of atresia 18 died of 
rupture of the Fallopian tube. 

The right time, then, to operate for complete atresia is as soon as 
the uterine tumor fairly fills the pelvis, and when by touch through 
the rectum with the finger, with a catheter in the urethra, we can 
assure ourselves that the uterus can be easily reached without en- 
dangering any important organ. 

Scanzoni was so impressed with the danger of wounding the blad- 
der and rectum that he advises evacuating the imprisoned menstrual 
fluid by introducing a curved trocar, of large calibre, into the rec- 



ATRESIA VAGINA. 69 

turn, and plunging it into the most dependent part of the tumor. 
After the flow of blood has ceased, the can u la should be left in the 
place for some time in order to establish a permanent opening. I 
think the danger of this operation is overestimated by Scanzoni, and 
cannot recommend the student to follow his teaching. With the 
precautions as to time and circumstances, and the proper care, the 
hazard is much less than he has estimated it. The patient may be 
placed in the lithotomy position, a catheter introduced into the blad- 
der and a finger into the rectum. The catheter will be directed strongly 
up behind the symphysis pubis, and the finger pressed firmly back 
against the sacrum. These preliminary measures being instituted, an 
exploring trocar may be passed into the central line of the vulva 
about half an inch below the urethral orifice, and pushed backward 
into the tumor. If the trocar has entered the cavity containing the 
menstrual fluid, this will begin to pass the canula upon the with- 
drawal of the stilet. When thus assured of the right direction, we 
may be guided by the trocar in an incision that should be run along 
the lower side of it, until the opening is large enough to press the 
forefinger through it. With this member we may tear the opening 
large enough to admit the middle finger with it. Through this open- 
ing the blood will soon be evacuated. As soon as this is the case, 
the cavity of the uterus and vagina ought to be thoroughly cleansed 
by tepid water thrown plentifully through a tube long enough to 
reach to the fundus. The artificial opening thus made must be kept 
open by confining a glass plug large enough to keep it patulous. 
This plug should be worn for several weeks and recourse be had to 
it when retraction threatens to obliterate the canal. 

Hewett recommends tearino^ throuo^h the obstructino^ tissue instead 
of puncturing or cutting. Others dissect through with the knife. 
Dr. Emmet advises us to use the scissors for incision into the tumor. 
And, again, a large trocar sometimes is used to penetrate the cavity 
at the point I have directed, and the finger used to enlarge the open- 
ing made by it. It happens in some cases that severe symptoms 
follow this operation for the sudden evacuation, such as peritonitis, 
metritis, etc. Dr. Sims, to avoid this, evacuates the fluid very 
slowly, allowing the uterus to contract on the receding fluid as fast 
as evacuated. 

In cases where a membrane closes the vaginal canal, the considera- 
tions above stated should induce us to wait until there is a moder- 
ate accumulation of menstrual fluid in the vagina. The division 
may then be made with scissors carried up to the membrane. The 



70 AFFECTIONS OF THE VAGINA. 

opening should be free. Not much danger will exist of cicatricial 
contraction closing up the divided part, yet for several days the finger 
should be passed above the obstruction daily to prevent any tendency 
of that kind. When the vaginal canal is contracted to very small 
dimensions, amounting to almost complete atresia, we may dilate this 
small opening by introducing sea-tangle tents or metallic bougies grad- 
uated in size, the smaller first and larger afterwards. Sponge- tents 
may be used after the dilatation has been fairly begun. Perseverance 
in the use of tents will enable us to succeed without cutting, and I 
would very much prefer it to any other method of procedure. 

Tumors in the Vagina. 

Fibrous tumors in the vagina are occasionally met with. They are 
generally less firm, although resembling in most other respects the 
fibrous growths of the uterus. They grow in the anterior wall of the 
vagina so as to project into the bladder and vagina to about the same 
extent, or more or less in either of these cavities, according as they 
are developed nearest the membrane of the one or the other. Some- 
times they are pendulous or polypoid, hanging into the vaginal cavity 
by a neck of greater or less size. All I have seen of the intramural 
form of these tumors were encysted, and were removed by excision. 
The cyst was opened and the tumor turned out and the wound al- 
lowed to close by contraction and granulation. The polypoid form 
may be removed by the ecraseur or ligature. The ecraseur is very 
much to be preferred. Fatty encysted tumors of the vagina are more 
rarely met with, and may be dissected out, in the same manner as if 
situated elsewhere. 

Vagi^iismus. 

Dr. Sims described this affection first to the Obstetrical Society of 
London, December, 1861, and has since given it to us in his Clinical 
Notes on Uterine Surgery. It is an " hypersesthesia of the vulva 
and hymen, attended with involuntary contraction of the sphincter 
vaginae." The parts are so very sensitive that the slightest touch with 
the finger causes great pain, and in some instances, coition is entirely 
impracticable. In all the cases I have ever examined, there was very 
decided redness and increase of the secretion of the parts exposed by 
separating the labia. Dr. Sims thinks that the sensitiveness is confined 
to the vulva and hymen, but I apprehend that more extended observa- 
tion will convince him that the whole vaajina is often involved. In 



VAGINISMUS. 71 

one of my cases, now under treatment, the sensitiveness of the vulva 
has almost entirely disappeared ; the finger may be introduced into 
the vagina, but the upper part of this cavity is so exquisitely tender 
that the patient screams with pain as the finger approaches the cervix 
uteri. 

The general symptoms of this affection are grave according to the 
chronicity of the case. It generally shatters the constitutional ener- 
gies of the patient, rendering her, according to the expression of Dr. 
Sims, a wreck. Dr. Sims says it is independent of inflammation. 
Mr. I. B. Brown agrees with him. It is, according to them, mere 
hypersesthesia. In my cases the parts were always in a state of 
inflammation ; but I cannot think the hypersesthesia was wholly of 
inflammatory origin. Of course I am not prepared to say that inflam- 
mation is even a general attendant. The observation of the profession 
will soon determine that point, as the disease is now fairly set before 
it, and, from its distressing symptoms, will attract much attention. 
My patients have apparently not been aware of their condition until 
married. The intensitv of the sufferins^ is not alwavs sufiicient to 
prevent coition, and sometimes is much greater than others. The 
sensitiveness is greater near the menstrual epoch, occasionally in a 
very marked degree. My patients have all been barren. 

Diagnosis. 

The sensitiveness and contraction are characteristic, and hence 
there is no need of much labor in formino; a diao^nosis. The least 
touch of the mucous membrane of the vulva, with a feather, soft 
brush, or fingers, gives the patient great suffering, and sometimes 
agony unlike anything else. 

Prognosis. 

Judging from all I have seen and read upon the subject, there is 
very little, if any, tendency to spontaneous subsidence. Its duration, 
therefore, is perplexingly long. But all agree as to its curability. 

Treatment. 

Dr. Sims has succeeded in curing all his cases by dividing the 
sphincter vaginae deeply on either side of the vaginal orifice. He 
makes the division sufficiently deep to permit of free dilatation, and 
then keeps the vagina open with large bougies until the wound cica- 
trizes. The results of this operation are all that might be expected 
from it. The hypersesthesia disappears, and the obstacles to coition 



72 AFFECTIONS OF THE VAGINA. 

are removed, but there is necessarily great mutilation. A long time 
Wfore Dr. Sims wrote on the subject, forcible dilatation was recom- 
mended to overcome the spasmodic contraction of the sphincter va- 
giure. Perhaps the best and most convenient way to dilate the vagina 
is to introduce the thumb of each hand into the vagina, with the 
palmar surface turned outward, and then forcibly separate them as 
far as possible. This will stretch the vulva, but not often rupture 
the muscular fibres to any great extent. After thus forcibly dilat- 
ing, we should introduce the glass plug, recomuiended by Dr. Sims, 
twice a dav. mornino; and evening:, and allow it to remain each time 
from one to two hours. The plug ought to be from one to two 
inches in diameter. The in tro<^l notion and presence of this hard sub- 
stance at first gives great pain, and we may be under the necessity ot 
using anaesthetics or anodynes, to enable our patient to bear it ; but 
after having been several times introduced, the parts tolerate it better, 
and finally we can use it without giving the patient any great incon- 
venience. The decreasiug sensitiveness thus manifested will be a 
guide to us in deciding when to discontinue ir. Mr. I. Baker Brown, 
in his Surgical Diseases of Females, condemns Dr. Sims's operation 
as severe and needless, and gives two cases where the sensitiveness 
was cured by the relief of fissure of the rectum. He thinks the hy- 
persesthesia is a symptom of some disease of the rectum, generally 
fissure ; and that by incision of the fissures it will disappear. Dr. 
Braun, of Vienna, according to Mr, Brown, has curefl one case by 
removing the clitoris. A case of some severity is reported in the 
Lonrlryn Lo/iicd, American repriut for March, 1867, in the care of 
Dr. G. C. P. Murray, in which the hypertesthesia appeared to de- 
j>end upon iuliammation of the cervix uteri and vagina. It was 
cured by making a free application of the solid nitrate of silver over 
the inflamed cervix, and a solution to the vaginal surface. These 
applications were repeated in a fortnight, and were succeeeled by the 
tincture of iodine. While there c-an be no doubt that Dr. Sims^s 
plan is efficacious, I cannot think it necessary-, and the success of 
other means by different practitioners bears me out in this opinion. 
We almost always find the patients in a state of unsatisfactory 
health, and, according to my observation, evident local disease be- 
sides that of sensitiveness ; and, from what we have learned from Mr. 
BroM-n and Dr. Murray, more than one kind of local disease. As in 
the treatment of all other diseases, therefore, we should carefully and 
diligently search for and cure the cause of the hypertesthesia. If it 



ACUTE VAGINITIS. 73 

is fissure of the rectum, this should receive our first attention ; if in- 
flammation of the vagina, uterus, or vulva, Ave ought to cure this. 

In all the cases I have seen, and I now have three under treatment, 
nothing I have tried has been of so much advantage as remedies di- 
rected against inflammation of the vagina and vulva. The course I 
usually pursue is to apply the solid nitrate of silver to the vulva 
every ten or fourteen days, and in the interval use glycerin and tannin. 
The first application reduces the sensitiveness very decidedly, and it 
becomes less after each successive touch, until finally cured. We 
should bear in mind that the hypersesthesia does extend into the 
vagina and to the uterus, and that it is as necessary to treat the vagi- 
nal cavity as the vulva. I have been in the habit, at first, of man- 
aging it as I would vaginitis. The strong astringents, glycerin and 
narcotics, applied by means of medicated pessaries and injections, are 
valuable adjuncts. With the local treatment, rational general treat- 
ment is very beneficial. Attention to the bowels, the condition of the 
stomach, and the secretions generally ; tonics, exercise, change of air, 
bathing, attention to clothing, and all the regimenal circumstances 
calculated to benefit the general condition of the patient. 

Acute Vaginitis 

Begins generally in the lower part of the vagina, with swelling, 
intense redness, and dryness of the mucous surfaces of the labia, 
vulva, and vagina. There is great heat in the parts, and the 
patient complains of burning pain in them. Difficult, painful 
micturition, pain in passing the faeces, sense of weight in the 
pelvis, and tenesmus are generally present also. Not unfrequently 
there is backache and pain, radiating down the thighs, into the hips, 
up the spine, and into the head. Sometimes the symptoms are so 
acute as to produce general febrile disturbance. When this is the 
case, there is chilliness alternating with heat, an increased frequency 
of the pulse, furred tongue, pain in the limbs, etc. In the course ot 
thirty-six hours the pain, redness, and swelling spread to the whole 
of the vaginal cavity, and soon there is a profuse secretion of mucus, 
which, after two or three days, or even sooner, is mixed with pus- 
globules in some abundance. When this last is the case, the dis- 
charge is either green or yellowish in color, and less tenacious. This 
state of things lasts for from ten to twenty days, when the inflamma- 
tion gradually subsides, becomes less in quantity and lighter in color, 
until in four or five weeks the disease is entirely gone, or it merges 
into the chronic form. The inflammation usually involves the urethra, 



74 AFFECTIONS OF THE VAGINA. 

and sometimes the bladder, and its greatest intensity is almost always 
in the lower third of the vaginal canal. The inflammation some- 
times spreads to the rectum. Sometimes it attacks the mucous mem- 
brane of the cervix uteri, and even invades the cavity of the corpus 
uteri, remaining longer in these localities than iu the vaginal cavity. 

Diagnosis. 

The diagnosis of acute vaginitis is not difficult, as the parts may 
be easily seen and touched. 

Prognosis . 

As has been heretofore intimated, it subsides spontaneously, and 
leaves the parts free from disease, or in a state of chronic inflamma- 
tion. The prognosis, therefore, is favorable. 

Cause. 

It is caused by contagion more frequently, perhaps, than anything 
else, but does doubtless arise from abuses, injuries, and want of clean- 
liness, and probably other causes. I have seen the non-contagious 
form in children very much more frequently than in adults, spreading 
usually from the vulva upwards. Non-contagious acute vaginitis 
is not a very common aifection. At first it involves the mucous 
membrane and submucous tissue, but before many days it is confined 
to the membrane alone. 

Treatment. 

This at first should be slightly antiphlogistic. A few grains of 
calomel, followed in ten or twelve hours with a saline cathartic, 
should be the first step. This may be succeeded by nauseating doses 
of tartar emetic, until the dryness and swelling have subsided. In 
the meantime, perfect quietude in the recumbent position should be 
enjoined, the parts bathed every hour or two thoroughly with tepid 
water, and the patient should abstain from stimulating or nutritious 
ingesta. As soon as the discharge has become copious, and yellowish 
or green, and the swelling of the parts has entirely subsided, the 
treatment should be changed for astringents, specifics, laxatives, and 
baths. We may give half a drachm of balsam copaiba in emulsion 
or ca]isules every six or eight hours, and have the vagina syringed 
copiously with a saturated solution of alum, or acetate of lead, two 
or three times in twenty-four hours. Every third day a few ounces 
of a solution of nitrate of silver, the strength of ten grains to the 



CHRONIC VAGINITIS. 75 

ounce, may be advantageously used. The bowels sliould be kept 
open, and the patient should abstain from stimulants at all times 
during the treatment. The astringent injection ought to be changed 
every five or six days, using alum, sugar of lead, and sulphate of zinc 
alternately. Perseverance in this treatment will very materially 
shorten the course of the disease. 

Chronic Vaginitis. 

This is a more frequent form of disease than the acute, and its im- 
portance will be understood from this consideration. It is in many 
instances a very distressing affection, and often mistaken for diseases 
of the uterus, bladder, or rectum. 

Symptoms. 

There is generally pain in the back, more frequently in the sacrum 
and coccyx, but not seldom higher up ; pain in the groin, weight and 
sense of bearing down in the perinseum, dragging in the hips and 
pelvis. A burning sensation in the vagina, extending all over the 
lower part of the person, very distressing and depressing, is some- 
times the chief symptom complained of by the patient. In married 
patients it is the cause of distress during the act of coition, to such a 
degree sometimes as to entirely preclude such indulgence. I am 
now treating a patient who assures me that although she has been 
married fifteen years, she does not remember a single instance of sex- 
ual intercourse that did not give her discomfort; generally it was the 
cause of decided pain, and sometimes was entirely intolerable to her. 
Leucorrhoea is a common, but not invariable symptom ; it may be 
yellow or white in color, but when the case is not complicated with 
cervical inflammation it is always thin. In chronic vaginitis there is 
generally a long train of sympathetic symptoms not unlike those ob- 
served in diseases of the uterus. The nervous centres are disordered 
in their functions, and we have nervous symptoms of almost every 
description. The mind is sometimes affected by it to irascibility, 
despondency, suspiciousness, peevishness, and purposeless instability. 
In other or, perhaps, the same cases there is palpitation of the heart 
and large vessels to such a degree as to cause alarm for the life of the 
patient. Headache should be mentioned as quite common ; it is 
more commonly located in the occipital region, but may be in the 
top, forehead, temples, or all over the head. The eyes are generally 
weak. The stomach is frequently deranged to a considerable extent, 



76 AFFECTIONS OF THE VAGINA. 

and in various ways ; and there is generally a constipated state of the 
bowels, though diarrhoea is an occasional symptom. There often is 
pain, too, in urinating, and in passing the faeces through the rectum. 
The uterus is almost always affected, also, and through it the symp- 
toms mav become sreatlv diversified and increased. We should ex- 
pect this complication. 

Diagnosis. 

Upon examining the vagina, the introduction of the finger will 
give some pain, sometimes a good deal, and the speculum causes a 
great amount of suffering. There is general redness of the mucous 
membrane ; sometimes it is smooth and moist merely, or covered with 
a copious secretion of mucus ; in some instances numerous granu- 
lations may be seen. The granulations may be situated at the 
upper end of the vaginal cavity entirely, as I have often seen, or the 
lower portion of this cavity may be the location in which they are 
found ; rarely they extend from one end of the vagina to the other. 
And again the membrane may be so raw as to bleed upon the use of 
instruments in making the examination. The sensitiveness, redness, 
and exaggerated secretion are conclusive and diagnostic symptoms 
when they are permanent. 

Causes. 

Chronic vaginitis is often the result of an acute attack. The in- 
flammation only partially subsides at the time, and is continued in- 
definitely. Some of the most obstinate cases I have met with have 
thus resulted from gonorrhcea. Another set of cases are seen in 
patients whose husbands were the subjects of syphilis in early life, 
but who have been to all appearances cured. I am inclined to the 
opinion that chronic vaginitis is not an uncommon occurrence in 
women thus situated. It is more likely to follow recent cases of 
syphilis, and is sometimes subacute in grade. Another form is ap- 
parently produced by abortions, colds, and other causes, with, at the 
same time, inflammation of the cervix uteri. Constipation, causing 
sluggishness of the vaginal circulation, or other causes producing this 
vascular condition, as the pressure from pelvic tumors, phlegmonous 
effusion, etc., contribute to the production of chronic vaginitis. There 
is no doubt but that certain constitutional taints, as scrofula, rheuma- 
tism, and, as before intimated, syphilis, are efficient co-operating causes. 

Prognosis. 

Chronic vaginitis, in its simpler forms. Is apt to be obstinate and 
resist judicious treatment for years. It is more particularly so when 



CHRONIC VAGINITIS. 77 

oricrinatino; in constitutional diseases. When connected with incurable 
tumors it will, of course, resist all sorts of treatment. 

Treatment. 

The constitutional treatment of chronic vaginitis is sometimes or 
the first importance, while at other times it is unnecessary, or nearly 
so. The variety which seems to be connected with the syphilitic 
condition requires the alterative remedies which are found beneficial 
in this affection under other circumstances, the preparations of mer- 
cury, iodine, and the vegetable alteratives, for instance. AYhen asso- 
ciated with scrofula, the vegetable tonics, with alterative treatment, 
cod-liver oil, plenty of outdoor exercise, cold bathing, sea bathing, 
etc., will be appropriate measures to be employed. As it is not un- 
frequently complicated with rheumatism, or this diathesis, it may be 
necessary to prescribe for it with such a consideration in mind. 

But in more simple cases, where there are no such taints or com- 
plications, conditions exist that require a judicious course of general 
treatment for their removal before we can be successful in our main 
object. Such is a torpid state of the bowels and portal circle, w4th 
scanty secretions. Mercurial and saline laxatives, vegetable tonics, 
as the bitters, also alkalies, will, when judiciously used, assist us verv 
much. We should be particularly careful to avoid a loaded or im- 
pacted state of the rectum, as this is the cause of much vaginal con- 
gestion. An injection once or twice a day, when necessary, will 
suffice for this. 

In all forms, in addition to the general treatment, when that 
is necessary, we shall be under the necessity of resorting to local 
measures. Much benefit will be derived from a sitz-bath twice a 
day. The bath should be tepid, as a general thing, as being more 
likely to agree with the largest number of patients. When it is 
more agreeable, the bath may be coolor. It should be large enough 
to cover the hips, and the patient should remain in it for an hour at 
least, and often it is better to use it for a greater length of time. Ot 
more importance are injections. Simple water in large quantities is 
sometimes sufficient, but more frequently astringent substances will 
be found essential. The injections should be administered through 
a perpetual syringe, and the quantity should be large, say from one 
quart to a gallon of water at each time. The common astringents, 
as alum, sulphate of zinc, acetate of lead, of the strengtli of one 
drachm to the quart of water, will generally suffice. We find cases, 
however, in which none of these substances can be used, because they 



78 AFFECTIONS OF THE VAGINA. 

disagree with the patient, producing dryness of the parts or increasing 
the inflammation. In such cases we must carefully search for the 
right local remedy. AYe may find it in tannin, tincture of the chlo- 
ride of iron, astring^ent decoctions, nitrate of silver in solution, etc. 
The last, used once in four or five days, with a glass syringe, and the 
other astringents between, often proves to be the best course. 

An excellent and very convenient mode of applying medicinal 
substances to vaginal surfaces is to make small sacs of gauze or 
linen, and fill them with the substance intended for use, and introduce 
them into the vagina. A sac the size of a small glove finger, with a 
piece of thread attached to it, will hold an abundance of almost any 
remedy we desire to use. Tannin in powder or ointment, gall oint- 
ment, belladonna ointment, and other articles are used in this way. 
A mixture I have used very commonly consists of two drops of crea- 
sote, half drachm of tannin, and one grain of belladonna extract, in- 
troduced at bedtime each night. The little bag may be removed in 
the morning by traction on the string. There are, I think, some 
advantages in the use of these little bags over the other sorts of medi- 
cated pessaries used. I not unfrequently inclose copaiva capsules in 
these little sacs, and think it an admirable mode of making balsamic 
applications to the vaginal mucous membrane. Where the astringents 
or other remedies are thus used they Avill not replace the injections 
wholly. Indeed, the vagina should be well washed out before the 
introduction and at the time of the removal of them. Patients^ of 
course, can manage these applications without aid. 

Perseverance and time are important items in the treatment. If 
we can remove this chronic inflammation in three or even six months, 
we ought to be satisfied. And we ought not to be surprised to have 
it return one or more times after it is apparently cured. It is well, 
also, to teach our patient patience in this respect. 

Puerperal Vaginitis. 

It might not seem necessary to consider the vaginitis occurring 
after labor as a separate affection, but there is so much difference — 
in the causes, nature, symptoms, and termination — between ordinary 
vaginitis and this form that I think it may be profitable to do so. 
In some cases of labor, circumstances occur that induce a severe form 
of inflammation of the vagina. The one most potent is long deten- 
tion of the fetal head in the pelvis. The pressure thus exercised upon 
the vaginal walls interrupts the circulation more or less completely; 
and if continued for a number of hours, violent reaction in the parts 



PUERPERAL VAGINITIS. 79 

results when the pressure is removed. This pressure does not affect 
the mucous membrane of the vagina so deleteriously as the deeper- 
seated tissues. The fibro-celkdar part of the vaginal walls is the seat 
of the inflammation. I do not think the use of instruments, however 
awkwardly, does so much damage as the long-continued pressure. It 
must not be denied, however, that instruments do give origin to this 
form of inflammation. When they do so, the inflammation is more 
circumscribed ; it does not extend to all parts of the vagina, as is apt 
to be the case when pressure by the child's head has been the cause. 
On account of the nature of the causes, this form of vaginitis runs its 
course rapidly, and is most sure to end in structural lesions. It is in 
intense forms of this sort of vaccinal inflammation that slouo^hs and 
deep ulcerations are met with, which open the bladder and cause 
vesico-vaginal fistula, recto-vaginal fistula, and cicatrices, which re- 
sult in contractions and even occlusions of the vagina. It is aston- 
ishing how much destruction sometimes is effected by intense post- 
partum inflammation. I remember being called to a case, in consul- 
tation, where the child's head had been pressing down sufficient to 
bulge the perinseum and labia for sixty hours without any motion. 
I delivered her with the short forceps in a few moments, without any 
violence to the parts. The patient was then unavoidably left in the 
hands of the same careless practitioner that had so outrageously 
neglected her before the delivery. I saw her three months after- 
wards, and found the whole septum between the bladder and vagina 
gone, the urethra terminating abruptly, as though it had been cut 
straight across, in a great irregular cavity, that was bounded by the 
pubis before and the uterus behind, and without any defined sides to 
it. In still a worse case, where shoulder presentation had prevented 
the passage of the child, the woman was in the second stage of labor 
six days. The woman arose from her bed with a large un definable 
cavity, — without any bladder, apparently, but the very top portion, 
— and the loss of two inches of rectum, into which the urine and 
faeces were poured involuntarily. In more than one instance I have 
seen the whole vagina sealed up, from the fourchette to the urethra, 
and, — as far as I can judge, — to the os uteri, as the effect of intense 
and neglected puerperal vaginitis, arising from unaided difficult 
labor. Every practitioner must meet with cases in which the cavity 
of the vagina is misshaped, and partially closed, from the cicatrices 
resultinor from it. Xow, much of these direful effects mav be averted 
by the rational management of inflammation after it hns been in- 
itiated. 



80 AFFECTIONS OF THE VAGINA. 

Symptoms. 

When injurious pressure has awakened inflammation in the vagina, 
the labia and walls become swollen, hot, and very tender. The 
patient does not generally complain of much severe pain, but there 
is a sense of soreness and heat. There is almost always fever, chilli- 
ness, and other evidences of disturbance of the circulation ; the tongue 
is coated, ordinarily white, sometimes yellow, or even brown, from 
the beginning. As the disease advances, two or three days from the 
beginning, the discharge from the vagina becomes more than ordi- 
narily fetid, the labia excoriated, while the heat of the vagina is still 
verv great, and there is much mucus and some pus issuing from it ; 
and later, shreds of decomposed substances, and sometimes consider- 
able sloughs, are mingled with the discharge, increasing the fetor. 
The pulse is more accelerated, and sometimes becomes quite rapid ; 
the patient is much prostrated ; the tongue brown and dry, and the 
teeth foul with a dark clammy mucus, while the skin is bathed in a 
copious perspiration. In from two to six or eight days, to these 
symptoms is added an evacuation of urine through the vagina, at 
first small quantities, and afterwards more considerable, until, in a 
short time, the contents of the bladder are passed through this way ; 
the parts around are excoriated by the urine and other acrid dis- 
charges, and a slow, uncertain convalescence succeeds, with a per- 
manent vesico-vaginal fistula. Occasionally, though not so frequently, 
the faeces pass through the vagina a few days after the beginning 
of the inflammation, and we have a recto- vaginal fistula. If neither 
of these evils occur, there is extensive ulceration, not so deep, but 
extending over a large surface of the vagina; thus pus and acrid 
ichor are poured out in copious quantities, for a long time, gradually 
decreasing as the surface heals. As these ulcerations heal up, the 
tissue becomes condensed and contracted, until such strictures or oc- 
clusions result as are above mentioned. The practitioner should be 
wide awake to this frequent course of post-partum vaginitis. 

Treatment. 

As most damage from this form of vaginitis usually accrues to the 
bladder and rectum, our first and most solicitous care should be be- 
stowed upon them. The bladder should be frequently emptied with 
the catheter ; at least every few hours the urine must be drawn oif. 
To appreciate this direction, we have but to remember that this 
organ may be considerably distended in that time, and as the septum 



URINARY FISTULA. 81 

between the vagina and bladder is in a state of intense inflammation, 
it is softened, and therefore is easily ruptured. My impression is 
that fifty per cent, of the vesico-vaginal fistulae which now occur 
might be avoided by following this rule. Its importance cannot be 
overestimated. In very bad cases the catheter might be used even 
more frequently, or kept in the urethra. The rectum should be 
kept free from any accumulation of fseces by frequent injections of 
tepid water. In addition to this prevention of fistula, the utmost 
cleanliness must be observed. The vaorina should be washed out 
with soapsuds or other bland detergent fluid, from four to six times 
a day. For the first four or five days the parts may be kept lubri- 
cated thoroughly by the injection, after the water, of very bland 
sweet oil, or almond oil. AVheh the slough begins to be thrown oiF, 
or pus and sanies become copious, an injection of half a pint of tepid 
water, containing six or eight drops of creasote, twice a day, will 
serve to cleanse and stimulate the parts better than soap and water 
alone, which should be used between times. After the lapse of a 
week or ten days, if the ulceration is not healing, an injection of ten 
grains of nitrate of silver to the ounce of water may be used quite 
advantageously. This solution should be injected from a hard rubber 
or glass syringe, directed to the ulcerated part by the finger. As the 
case still further advances, a solution of tannin, alum, sulphate of 
zinc, or other astringents, with the detergents, may be used. As the 
parts begin to contract by the advanced healing of the ulceration, the 
closure, paitial or entire, should be anticipated by the introduction, 
daily or oftener, of wax, rubber, or other sort of bougies. It is 
well, when this last expedient is necessary, to smear them with oint- 
ment that may exert a healing influence on the ulceration. The 
physician cannot be too attentive to these cases. He should see to it 
personally that his directions are carried out, and feel himself respon- 
sible for any serious permanent injury that can result from want of 
diligence. Women or their nurses cannot undei^stand, and it is 
feared that physicians do not properly appreciate, these means of 
averting^ the awful accidents which result from slouo^hino^ and ulcer- 
ation in these cases. 

Urinary Fistula. 

Although generally resulting from puerperal vaginitis, fistula is 
sometimes produced by other causes. Extensive ulcerations from 
pessaries sometimes penetrate the septum between the vagina and 
bladder. Stone or other foreign bodies in the bladder may act as 



82 



AFFECTIONS OF THE VAGINA 



causes of ulcerative processes of sufficient gravity to do the sarue. 
Malignant diseases, as cancer of the uterus, vagina, or bladder, not 
unfrequently lay open these cavities; and, in some rare instances, 
perforations by the unskilful use of instruments have been observed. 
Urinary fistula may be: first, urethro-vaginal ; second, vesico- 
vaginal; third, vesico-uterine; and, fourth, vesico-utero vaginal. 
In the first variety the opening is through the urethra; In the second 
through the septum between the vagina and bladder; in the third 
the vesical wall of the cervix uteri is perforated ; in the fourth, two 
cases of which I have seen, the anterior and posterior portions of the 



Fig. 10. 



Fig. 11. 




cervix are both laid open. The cervix is sometimes involved with 
the vaginal septum, being torn up from the extremity through the 
anterior lip into the vaginal cavity. The whole urethra sometimes 
sloughs off, leaving the pubic arch unoccupied by that canal. In 
one case I have recently seen, the urethra aud neck of the bladder 
were lost, leaving the remainder of the vesico- vaginal septum healthy 
and entire. In certain other instances the whole lower portion of 
the bladder is wanting, and the uterus more or less mutilated. To 
make the condition more deplorable, in some rare examples of the 
terrible destruction of the parts, the rectum is involved in the common 



URINARY FISTULA. 83 

ruin. The size of the opening in the urethra or vasico-vaginal 
septum is sometimes so small as scarcely to be perceptible, and from 
this it may vary through all grades of dimension to the irreparable 
loss of tissue above described. The direction may be lengthwise, 
diagonal, tortuous, or crosswise. 

The fistula, when established, is usually associated with other effects 
of the disease from which it is produced. Cicatrices and contractions 
of the vaginal walls are very common accompaniments. These, when 
extensive, embarrass examinations and operations very much. They 
also change the size, shape, and direction of the vaginal cavity. 

Diagnosis. 

The constant flow of urine throuo^h the vasrina, instead of the 
urethra, is a sufficient symptom to decide the existence of fistula; but 
we meet with cases where the flow of urine is not constant, the patient 
being able to retain for some time and then discharge her urine nat- 
urally. This circumstance is due to the plugging of a small opening 
by mucus, or the prolapse of some part of the bladder into the fistula. 
In all instances it is proper and necessary to make a clear diagnosis 
of the existence, size, shape, position, and complications of the fistula. 
This is usually easily done by the fingers and probe. The patient 
should lie on her back with her hips near the edge of the bed, and 
her legs flexed so that we may have free use of both hands. The 
fingers will readily pass through a large fistula into the bladder, and, 
by moderate care, be made to thoroughly survey it and the surround- 
ing parts. But the fistula may be so small or situated so as to entirely 
escape detection by the finger. We shall be aided in such cases by 
introducing a probe, slightly bent, through the urethra with one 
hand, while the fingers of the other are in the vagina. The bent 
extremity of the probe is turned toward the septum, pressed gently 
upon and passed over every part of it until it is made to pass through 
the opening, when it may be recognized by the finger in the vagina. 
When the perforation is very small, or vesico-uterine, this kind of 
examination will fail to find it. In such cases the vagina should be 
dilated as for operation, and exposed in a good light so that every 
portion may be seen. When thus exposed, the cavity should be 
sponged out and all the urine thus removed. After this perforation, 
usually we have but to watch a few moments when we shall perceive 
the fluid making its appearance through a minute pore, which, per- 
haps, is hidden in an ulcer in some remote part, or we may observe 
it coming through the os uteri. If, however, no urine makes through 



84 AFFECTIONS OF THE VAGINA. 

in such quantity as to indicate the place of injury, we may inject the 
bladder with tepid water in such amount as to distend the organ 
somewhat. Soon the obstacle is overcome and the water will escape 
copiously into the vagina. If it comes through the mouth of the 
uterus, the fistula is situated in the cervical cavity. This may be 
made more conclusive by plugging the os with cotton and again in- 
jecting the bladder. The fluid will not escape, of course, until the 
cotton is removed, when it will pass in such abundance as to leave 
no doubt of its place of exit. German physicians, Yeit especially, 
recommend the use of water colored so as to make its flow through 
the opening more obvious. 

Prognosis. 

Having found the fistula, ascertained its size, position, shape, direc- 
tion, etc., we ought to survey the vagina, to find strictures or other 
deformity, and ascertain the distensibility of this tube. We do this 
in part to determine the prognosis of the case. Can the fistula be 
cured ? is a pertinent and important question, which will be decided 
by this kind of examination. Fortunately, now, thanks to Dr. 
Sims, almost anything short of loss of the whole septum may be 
cured. If the fistula consists of a defined opening, it matters little 
how large, we are justified in expecting success. If, as is sometimes 
the case, there are no sides, edges, or ends to it, but the vagina and 
bladder are one cavity, smooth, and continuous, we cannot reason- 
ably undertake an operation unless it be to close the vulva, as 
has been suggested and practiced. Some circumstances, indepen- 
dent of the character and size of the fistula, are necessary to insure 
success. The vagina should be healthy. If the walls of this cavity 
are in a state of inflammation or congestion, the prospects of a cure 
are more remote. Great nervous susceptibility is sometimes difficult 
to overcome, and should be a reason to defer the operation. The 
general health of the patient is also a matter of the first importance. 
A highly nervous condition of the system, with an abundance of 
lithates in the urine, is a condition in which there are many chances 
of failure. 

Treatment 

Naturally divides itself into palliative and curative. 

The palliative treatment is of great importance, and he would be a 
benefactor who should devise means of preventing the great suffer- 
ing which results from these inevitable circumstances. The greatest 
amount of pain and suffering in such cases is caused by the flow of 



URINARY FISTULA. 85 

urine over the cutaneous surftxce. The salts held in solution by the urine, 
and the compounds resulting from their chemical decomposition inflame 
and excoriate the skin of the thighs, perinseum, and external genital 
organs. Relief can be perfect only by preventing the contact of the 
urine with the skin. I think there would be no difficulty in making 
an instrument that would collect the urine, in most cases, before being 
discharged from the vagina. But the difficulty consists in getting 
one that would be tolerated in the parts. What we want is a sac 
that may be introduced and retained in the vagina with an opening 
in the upper wall opposite the fistula, large enough to permit the 
urine to flow in it. The sac should have a tube leading out of the 
vaginal orifice in order to convey the urine into a reservoir outside, 
which should be attached to the person of the patient. The sac 
should be of india-rubber or other impervious material, and so soft and 
smooth as not to irritate the mucous membrane of the vagina, and 
so small as not to distend the vagina painfully. But the urine 
would not flow into and through this tube unless the sac was dis- 
tended so that the opening would be applied to the fistula. The dis- 
tension may be effected after the sac is introduced, by passing cotton 
up through the tube until sufficiently distended. In order to make 
the urine drain through the tube something like cancellarige should 
extend from the cotton in the sac outside through the tube. The drain- 
age will be started by wetting the contained material. The capillary 
attraction of the cotton will absorb the urine until it becomes satu- 
rated, while the loose cord will carry it off* like a siphon through the 
tube. If an instrument of this kind can be made that will be tol- 
erated by the vagina, I think it will act well. 

In the absence of anything to prevent the urine from flowing on 
the person, the patient must depend upon frequent ablution with 
warm water externally, and upon warm injections in the vagina. 
After washing externally, the skin should be kept covered with 
simple ointment. The injections should be made four or five times 
in the twenty-four hours, and the external ablutions as often as the 
napkins become sufficiently saturated to replace by others. 

Another item in the palliative management of the first importance 
is one mentioned by Dr. Emmet, viz., never to use a napkin twice 
without washing. Sometimes to avoid labor patients Avill simply 
dry the napkins and then use them again, thus using a napkin sev- 
eral times without washing. In this way the salts of the urine are 
applied to the skin in double strength, and the mischief greatly in- 
creased. 



86 AFFECTIONS OF THE VAGINA. 

The curative treatment consists ia the closure of the fistula. 

It is hardly necessary to mention any other method than the closure 
of the fistula by suture in some form or other. Cauterization was 
often resorted to before the present safe and sure plans of operation 
by Drs. Sims and Bozemau, but is now scarcely thought of. 

To Dr. Marion Sims we are indebted for the cure of vesico-vaginal 
fistula ; for although others had succeeded in making cures by the 
use of nearly the same means, his ingenuity and jDersevering industry 
gave such positiveness and intelligent definiteness to the different 
steps to be followed in order to succeed, as to convert the operation 
from one of great uucertaint}^, confined to experts and experienced 
operators, to an easy, almost invariably successful one, which any 
surgeon of ordinary skill may venture upon without fear of failure. 
The pix)fession is also indebted to Dr. Emmet, for a ver}' lucid demon- 
stration of the principles upon which the operation is founded, in his 
work on that subject. 

In describing the very simple operation of Dr. Sims one can 
scarcely do otherwise than follow, if not copy, the graphic description 
given by Dr. Emmet. Very much depends upon proper preparation 
of the system of the patient and the parts concerned, in order to in- 
sure successful adhesion of the two edges of the fistula. The patient 
should be in the best possible general health. I think there is great 
propriety in the distinction insisted upon by some surgeons between 
the plastic and aplastic diathesis in patients subjected to surgical opera- 
tions, and am anxious that my patients, for some weeks before the 
operation, be subjected to the best hygienic condition for their general 
health. In the country, if possible, plenty of exercise in the open air, 
good nutritious diet, a contented and happy state of mind are all 
that are required to effect the desired preparatory condition. In 
patients whose blood is impoverished from nursing, hemorrhages or 
other debilitating circumstances, the ferruginous and bitter tonics 
should be administered. If the general health is well established 
and maintained for a little time, the vagina will scarcely be other- 
wise than firm and sound in texture, and free from the troublesome 
urinary concretions that sometimes adhere to the mucous membrane 
of the vagina, the vulva, and even the greater labia. During the 
preparatory constitutional treatment, where that is necessary, the local 
preparation may be attended to — by frequent cleansing by copious in- 
jections of warm water, stimulating the parts in the vagina that are 
red or excoriated with a weak solution of nitrate of silver every four 
or five days. The solution may be of the strength of 5i to f^iv of 
distilled water. Dr. Emmet savs that : 



URINARY FISTULA. 



87 



" It is frequently necessary to pursue the same general course for 
many weeks before the parts can be brought into a perfectly healthy 
condition. This point is not reached until not only the vaginal wall, 
but also the hypertrophied and indurated edges of the fistula have at- 
tained a natural color and density. This is the secret of success, but 
the necessity is rarely appreciated ; without which the most skilfully 
performed operation is almost certain to fail." 

The only other preparatory step will be the administration of a 
cathartic to evacuate the bowels. The catharsis ought to be entirely 



Fig. 12. 



Fig. 13. 



Fig. 14. 




Fig. 12. — Tenaculum, with which to hold the edge of Fistula while being pared. 
Fig. 13.— Curved Scissors, for paring edge of Fistula. 
Fig. 14.— Wire Adjuster. 

over at least twelve hours before the operation. With these prelimi- 
naries accomplished, we should have a large window on the sunny 
side of the house, a sun-shining day, four assistants, a table of conve- 
nient height, five feet long and two wide, and the necessary instru- 



AFFECTIONS OF TUE VAGINA, 



ments. The table, covered with one or two quilts, is to be placed 
with the end toward the window, from four to six feet distant. The 

Fig. 15. 




Fig. 15.— -Speculum for dilating Vagina. 
Fig. 16.— F()rcei)s for twisting the Wires. 
Fig. 17.— The Catheter. 
Fig. 18.— Needle Forceps. 

Fig. 19,— Sponge-holder. The instruments are represented half 
size. 

patient lies on her leftside, the limbs drawn up, the right rather most 
with the left arm behind her, so that she rests full on the front of the 



URINARY FISTULA 



89 



chest. One of the four assistants uses the anaesthetic, another the 
speculum, a third the sponges, and the fourth attends to the instru- 
ments. On a tray, within easy reach of the operator, the instruments 
should be placed. They are the speculum, two tenacula, scissors, 
Emmet knife, two long sponge-holders, forceps for carrying the 
needles, one wire adjuster, a blunt hook, forceps to twist the wire, 
half a dozen needles, slightly curved, about one inch long, armed 
with silk ligature, doubled so that the silver wire may be placed in 

Fig. 20. 



Fig. 21. 





Method of passing the Needle. 



Method of paring the edges. 

the loop and thus drawn through the wound, an elastic male catheter, 
or one of Sims's S-shaped instruments, with an india-rubber tube, a 
little larger than the catheter, to carry the urine clear of the bed. 
The surgeon takes his seat at the end of the table next the window, 
near the breech of the patient, introduces the speculum, dilates the 
vagina, and thus brings the parts thoroughly in view, and then gives 
the instrument to the assistant to keep in that position. If the posi- 
tion of the patient prevents the parts from being thoroughly exposed 
and lighted, it should be changed until this difficulty is obviated, 



90 



AFFECTIONS OF TfiE VAGINA. 



when the operator may proceed as follows : With the tenaculum in the 
left hand, the edge of the fistula is transfixed and held up to view, and, 
with the scissors, bevelled from the mucous membrane of the bladder 
outward. Dr. Emmet says the point of the tenaculum should be in- 
troduced toward the fistula, as shown in the figure. As much should 
be removed in this way, without changing the place of the tenacu- 
lum, as practicable. Another place on the edge of the fistula is then 
seized and trimmed in the same manner, and so on, until the whole 
circle is denuded completely of the cicatricial tissue. We may some- 
times succeed after a little practice in removing a complete ring of the 
edge of the fistula. This will of course insure to us a more perfect 
operation than if the parts are removed in pieces. As this part of 
the operation is being accomplished, the assistance of the sponge will 

Fig. 22. 




Method of using the Tenaculum in giving aid to the Needle, 

be called into use on account of the bleeding. I do not see the neces- 
sity of removing as much substance from the edge of the fistula as is 
directed by some authors. 

The main object, I think, is to have the edges evenly and thoroughly 
denuded of the mucous membrane. This much should be done with 
a completeness that admits of no doubt, and if we have a good light, 
there need be no doul)t, as we can see and examine the part suffi- 
ciently well to be positive. After the bleeding has ceased, we may 
insert the sutures. We commence at the angle of the wound most 
remote and difficult to reach. The needle is to be introduced first 
into the lip of the wound nearest to the operator, by starting it in 



URIN-ARY FISTULA. 



91 



about half an inch from the freshened edge, dipping it down, so as 
to make the point come out iu the denuded portion, just at the junc- 
tion of it and the vesical mucous membrane. The needle being: 
brought through at this point, is again inserted in the opposite edge, 
corresponding as near as possible with that part whence it emerged, 
and carried forward far enoui^h to emergre half an inch bevond the 
edge of the wound, and drawn through ; the wire is then hooked in 
the double end of the silk and drawn through the wound, and de- 
tached from the silk and given to the assistant in charge of the 
speculum to retain in its place. The next suture is to correspond 
with and be placed within two lines of the first. They are thus 
placed in sufficient numbei-s to close the opening completely (see Fig. 
23). Having all the sutures introduced, the one nearest the operator 

Fig. 23, 





^ihiP" 




The Fistula witti edge p>ared and the Sutures placed. 

must be isolated and twisted by the forceps made for that purpose, 
until the angle of the wound is evenly coaptated. The next is to be 
managed in the same way, and so of the remainder in order. Great 
care must be taken to see, as the closure is effected, that the lips of 
the wound are drawn evenly and smoothly together (see Fig. 24). 



92 



AFFECTIONS OF THE VAGINA. 



If we are not particular, the edge of one side or the other rolls 
slightly in, and unfreshened mucous membrane is brought up to the 
denuded surface. This, I think, is a circumstance that is very liable 
to occur in the hands of an inexperienced operator. Both the inser- 
tion of the sutures and bringing together the edges may be facilitated 
by the skilful use of the tenaculum and the adjuster. The tenacu- 
lum will enable us to disengage and straighten the edges, in adjust- 
ing them, and in inserting the needles keep them firm. The adjuster 
will place the twist of the wire in any position with reference to the 
junction of the wound we may desire. In twisting the wire there 
are two things to be avoided, — one is tightening it too much, and the 
other leaving it too lax. Experience will fix these items after a few 



Fig. 24. 




Wire Adjuster. 



operations, but I think that^the operator may venture to tighten the 
twist of the wire until it fixes but does not strangulate the part in- 
cluded in the stitch. After the twist is completed, we ought to be 
able to pass an ordinary probe through the circle of the stitch with- 
out much force, and yet, upon its removal, there should be no 
apparent space. If the stitch is drawn too tightly, the parts will be 
strangulated and early cut through by ulceration ; if too loose, the 
urine will pass through as the bladder becomes filled and prevent 
adhesion. 

As each wire is adjusted and twisted it should be bent over the 
tenaculum, so as to lie flat upon the surface of the mucous membrane 



URINARY FISTULA. 



93 



of the vagina. The operation finished, the catheter may be inserted, 
the patient placed carefully in bed, on either side, and a grain of 
opium administered. The catheter will sometimes become foul with 
deposits, and require cleaning every twelve or eighteen hours, but as 
a rule, while the urine is running freely, it may remain in place. 
Great watchfulness will alone prevent this instrument from being 
misplaced. The great desiderata of the after-treatment, are to pre- 
vent an accumulation of urine in the bladder, and the bowels from 
being evacuated. The former can be certainly accomplished in no 
other way than by having a competent assistant by the patient, or 
very near her all the time, who, when the catheter docs not deliver 



Fig. 25. 



Fia 26. 




Closins the Wounds and Twisting the Wire Sutures 



Eemoving the Sutures. 



the water freely, will remove it and replace a clean one, however 
frequently that may be required. Dr. Emmet directs that the patient 
be placed upon her back and so remain during the after-treatment. 
He causes a double inclined plane to be made by the bedding, so that 
the legs may be bent and the head and shoulders elevated. AVe may 
keep the bowels quiet by administering a grain of opium twice or 
three times a day. If the patient is very restless, we ought to give 
as much more as is necessary to quiet this. The only other impor- 
tant item of treatment as a general thiuo^ is cleanliness, and for this 
purpose vaginal injections of tepid water, with fine toilet soap, twice 



94 



AFFECTIONS OF THE VAGINA. 



or three times a day, will suffice. The vagina will thus be kept clean 
with much certainty. The diet should not be too sparing. The or- 
dinary diet of the patient, in half or two-thirds of the quantity, I am 
convinced is better than any considerable change in quality. The 
patient must remain quiet as practicable for nine or ten days. There 
will be no good in leaving the sutures in place longer than ten days, 
perhaps, but there can no harm result from their presence longer. 
The removal of them is easily accomplished, by passing one blade of 
the scissors within the circle of the stitch, and dividing it, when the 
w^ire may be withdrawn by the forceps. The patient should keep 



Fig. 27. 




her position and wear the catheter for five or six days, after the 
sutures are removed, to allow the consolidation of the cicatrices and 
the closure, by contraction, of any minute opening that may have 
been left. 

Although the experience of Drs. Sims and Emmet has proven the 
propriety and efficacy of this kind of after-treatment for vesico- 
vaginal fistula, all of it is not absolutely necessary to success. In 
two instances operated on by the author, the patients were not con- 
fined to any position, and were permitted to rise from the bed and 
sit up part of the time each day, from the time of the operation until 



URINARY FISTULA, 



95 



the sutures were removed. The catheter was not worn in eilher case, 
but it was used for the first four days, every two liours, to evacuate 
the bladder. At the end of four days, the patients were })ermitted 
and instructed to evacuate the bladder as often as once in two hours 
voluntarily. 

Both the patients were cured, and the comfort they enjoyed con- 
trasted very favorably with that of such as were confined to the 
position on the side or back, and were obliged to wear the catheter 
for ten or fifteen days. I have, from time to time, seen suggestions 
in medical journals, which I cannot now command, that led me to 
conduct the after-treatment in these two cases as above stated. 

Simon^s Ilethod. 
In Continental Europe the late Professor Gustav Simon, at the 
time greatly distinguished himself in plastic operations. His opera- 

FiG. 28. 




tion for vesico-vaginal fistula is, in many respects, different from 
that above detailed. 



96 



AFFECTIONS OF THE VAGINA 



He places his patient on her back with the breech very much ele- 
vated. In cases where the fistula is near the orifice of the vagina, 
the limbs are placed in the position usual in lithotomy. If the 
fistula is deep, however, the limbs are brought up and extended over 
the sides of the abdomen and breast, as shown in Fig. 27. If the 
uterus is sufficiently mobile, Simon draws it down to the external 

Fir 9q 




organs of generation, and thus places the fistula immediately under 
the hand of the operator. In order to ascertain the mobility of the 
organ, he seizes the cervix with Museux's forceps, and draws upon it 
until the vagina is inverted, or until it is evident that the forcible 
traction required will do violence to some of the tissues. When the 
cervix is drawn down sufficiently, two strong threads are passed 
through it by which it is held in place. 

Fig. 28 represents this stage of procedure; the sides of the vulva 
being held out of the way by levers made for the purpose. 



URINARY FISTULA, 



97 



When the uterus cannot be thus drawn down, Simon uses two 
specula, and the levers in the sides of the vulva, if necessary. This 
method of exposure is very pkiinly illustrated by Fig. 29. One 
large speculum draws back the perina?um, and another, somewhat 
differently constructed, is placed under the symphysis pubis. 

Fig. 30. 




The margin of the fistula is prepared by cutting away all the cica- 
tricial tissue, and the paring is done almost perpendicular to the sur- 
face of the vaginal mucous membrane. There is some slight inclina- 
tion or declivity in the cut edges, but they are very much less bevelled 
than in Dr. Sims's operation. Fig. 30 will give a correct idea of 



98 



AFFECTIONS OF THE VAGINA. 



this part of the operation. A comparison with Fig. 30 will give the 
reader an idea of the liberality with which Dr. Simon considers it 
necessary to pare away the tissue. 

The wound is closed with fine white silk, about the size of a large 
horsehair. Each stitch is placed a little more than a line distant 



Fig. 31. 




from the one next to it. The needle is carried entirely through the 
lips of the wound, so as to penetrate the vaginal and vesical mucous 
membrane. In large fistulse, every alternate stitch is placed further 
from the edge of the wound. Fig. 31 also shows this method of in- 
troducing the stitches. The threads are carefully tied in a knot and 
the operation is completed. The closed fistula is well represented by 
Fig. 32. 



URINARY FISTULiE. 



99 



Yesico-uterine fistulse are operated upon in the same manner. 
Figs. 33 and 34 show how such fistulse are pared, the stitches in- 



troduced, and tlie wound closed. 



Fig. 32. 




In the after-treatment, Dr. Simon thinks it superfluous, if not in- 
jurious, to leave the catheter in the bladder. He directs us to draw 
off the urine once in two or three hours, until the patient can volun- 
tarily discharge it, which she can usually do in the second or third 
day. He allows the patient to lie in any position, and on the eighth 
or ninth day she can rise from the bed. All straining at stool, before 
the eighth or ninth day, should be avoided, if necessary, by the ad- 
ministration of opium. On the fourth or fifth day the physician 
should examine the wound with a view to the removal of the stitches, 
and if they are cutting their way through the tissues they should be 
cut and drawn out. 



100 



AFFECTIONS OF THE VAGINA. 



Of 43 fistula? in 40 women operated upon by Professor Simo'i, 35 
were perfectly cured, 2 of the women died, 5 more of the fistulse were 
nearly cured, and 1 was not benefited. 



Fig. 33. 




Kolpokleisis. 

Cases of urinary fistula occur which cannot be cured by an opera- 
tion like the foregoing. Occasionally we meet with instances in which 
the damage is more serious, where the septum between the bladder 
and vagina is nearly or completely destroyed, not enough of this 
structure being left to enable us to restore it. 

Surgery has successfully met these cases by closing the vaginal ori- 
fice or lower part of the vaginal canal, thus making a common 
receptacle of the posterior and lateral walls of the vagina, and the 
remaining portion of the bladder, into which the renal secretions and 
the uterine discharges are received and from which they find their way 
out through the urethral canal. The vagina may be closed by unit- 
ing the inner edges of the labia or the anterior and posterior walls 
of the vagina quite inside the orifice. The operation for uniting the 
labia will be necessitated in some instances. We occasionally meet 



URINARY FISTULA. 



101 



with cases where the anterior wall of the vagina is entirely removed 
from the pubis, and nothing is left behind that bone to which the 
posterior wall of the vagina may be united. So completely is this 
removal of tissue that the posterior face of the pubis is covered with 
nothino^ but a thin cicatricial substance. The labial closure of the 
vagina is the only resort in this class of extreme cases. 

The operation consists in removing a ring of mucous membrane 
from the inner margin of the labia, just behind the orifice of the 



FiCx. 34. 




urethra, three-quarters of an inch deep, and then by means of deep 
silver sutures making perfect apposition of the denuded surface. 
The sutures should be passed deep enough to include the whole of 
the raw portion of the parts, and extend on the outside three-quar- 
ters of an inch in the substance of the labia beyond their margin. 
The sutures, to insure union, should be not more than three lines 



102 



AFFECTIONS OF THE VAGINA. 



apart. The parts should be carefully adjusted while the wires' are 
being twisted, so as to make an even adaptation. 

When there is sufficient of the vesico-vaginal septum behind the 
pubis to permit its coaptation to the posterior wall, the operation 
performed and proposed about the same time by Simon and Bozeman 
is preferable to the foregoing. Simon's method is simple and efiPec- 
tual in closing the vagina thoroughly. He denominates the opera- 
tion Kolpokleisis. The vagina is held open by the instruments and 
by the method described for operating on fistulse^ and a ring of mu- 
cous membrane is removed as represented in Fig. 34, and then united 
by the sutures. Silver wire is probably the best suture for this op- 
eration. 

Dr. Simon operates as high up in the vagina as the disease will 
permit, and instead of confining the operation to the urethral portion 
of the cavity, he sometimes operates so near the os uteri as to preserve 
almost the entire length of the anterior wall of the vagina. After 
either operation the treatment will consist in perfect quietude, the 
use of opium to relieve pain, and the fixed catheter to prevent an 
accumulation of urine until the parts are healed. 

Bozeman' s Method. 

Dr. Bozeman, whose operations have attracted attention in Europe 
as well as in this country, claims to have made improvements upon 

Fig. 35. 




Bozeman's Apparatus for Retaining the Patient in Position. 

the operation for vesico-vaginal fistula as well as in the means and 
methods of performing it. As now employed his operation has for 



URINARY FISTULA. 



103 



its •distinctive characters the button suture, the position of the pa- 
tient, and a self-retaining specuhim. The figure which is here intro- 
duced will serve to illustrate the position of the patient and the 
self-retaining speculum. In paring the edges of the fistula Dr. 
Bozeman makes the extent of denuded surface rather greater than is 
recommended in the foregoing pages, and does not place his sutures 
as near together. After having prepared the parts for coaptation he 
passes the two ends of each suture respectively through the opening 
in his adjuster, as represented in figures taken from page 24 of M, 
Andrade essai sur le traitement de fistules veslco-vaginales par le 
procede Americain modeae par 31. Bozeman. Thus adjusted the 
wound is ready for the button, which should be made at the time 
and in accordance with the shape and size of the wound. The button 



Fig. 36. 




is cut out of a thin sheet of lead, about one line in thickness, long 
enough to project about one-fourth of an inch beyond the sutures at 
either end of the wound, and a very little more than half an inch 
wide. If the wound is straight after it is closed with the suture, 
the button should be the same ; but if the wound is curved the 
button should be made to suit the curvatures. Then with the 
^^button-forming forceps,'' the groove along the centre may be 
formed by clamping across the sides from one end to the other. 
Thus formed the button is slightly concave on the side that goes 
next the closed wound, and has a groove of almost a line in depth 
along the centre, from one end to the other, and is ready to be 
perforated for the sutures, which, after measuring off the distances 



104 



AFFECTIONS OF THE VAGINA. 



Fig. 37. 




accurately, is done by an instrument for the purpose. The operator 
should then assure himself that all the spiculse caused by the perfo- 
rating process are removed, and proceed to adjust the button. 

Fig. 36 shows the sutures through the button as it approximates 
its future site on the wound. The button is pressed down evenly 
upon the wound by means of the blunt hook, 
and each suture, one after the other, passed 
through perforated shot, and fixed by clamp- 
ing the shot with strong forceps for the pur- 
pose. Each suture should be carefully fixed 
in this way separately. 

In adjusting the sutures the wire should 
be tightened by being drawn through the 
opening at the time the shot is compressed. 
Only so much traction should be made as 
will bring the lips of the wound well up into 
the groove, but not strangulate them. 

The button thus applied is well represented 
by Fig. 37. Dr. Bozeman claims for this 
suture : 

** 1. Separate and independent action of the sutures. 

" 2. Perfect coaptation of the edges of the fistula, and power to hold 
them in a certain relationship during the reparative process. 

" 3. Perfect steadiness and support of the edges of the fistula. 

"4. Protection of the denuded edges of the fistula from the vaginal 
and uterine discharges, and from the urine, when there happens to be 
more than one opening, and it is not conveuieut or desirable to close 
both at the same sitting." 

We are indebted to Dr. Bozeman for a very ingenious and effectual 
method of diagnosing minute and otherwise indistinguishable fistulse. 
He calls it the linen test, and describes it as follows : 

" Pus and mucus in small quantities adhere to and spread upon the 
surface of a piece of linen without being absorbed by it, while water or 
urine, on the contrary, even in the miuutest quantity, when brought 
into contact with the same material, penetrates almost instantly the 
entire thickness of the fabric. The presence of these fluids, if the flow 
is continuous, is evidenced by increasing saturation of the spot acted 
upon, and the spreading of the moisture in every direction. Thus is 
presented a most valuable and reliable means of determining the presence 
of urine in the vaginal or uterine canal when the quantity is so small 
as to escape observation ; not only this, but the precise situation of its 



URINARY FISTULiE. 105 

escape from the bladder can be made with the greatest certainty when 
it would be impossible to detect it by the ordinary means, owing to the 
minuteness of the orifice or its concealment by a fold of mucous mem- 
brane. 

*' In using the test nothing more is necessary than to fill the bladder 
with water, and then wipe thoroughly dry the anterior wall of the vagina, 
A piece of old linen is now rapidly spread out upon the latter, aud 
pressed down smoothly, the patient being in the angular position, upon 
the knees. In a few moments the effect of the fluid upon the linen will 
be seen at the place of escape from the bladder, should the orifice be 
even no larger than a pin's point or a fine bristle. When the patient is 
placed in the dorsal position it is seldom necessary to inject the bladder; 
the natural flow of the urine from the kidneys will be found quite sufficient 
to mark the situation of its unnatural escape into the vagina." 

With regard to the success of his method of operation, as now 
practiced by hira, he givas the following data : 

*'For the period from 1867 to 1870, 17 cases, having 23 fistula?, got 
24 operations, with the following results : 

" 21 fistul^e completely closed. 

" 1 fistula completely closed in a syphilitic subject and afterwards 
reproduced. 

" 1 death, caused by intense heat of the weather and consequent 
exhaustion of the patient. 

"88 per cent, of permanent cures. 

" 87^ per cent, successful operations. 

"The syphilitic case was cured as regards the result of the operation. 
and the death did not result from causes connected with the operation. 
It will be seen, therefore, that the percentage of permanent cures and of 
successful operations is not far below the maximum limit. Of these 23 
fistulse 8 were vesico-uterine, 1 vesico-utero-vagiual, 1 utero-vaginal, 1 
laceration of the urethra, 1 urethro-vaginal and recto-vaginal, the latter 
admitting easily three fingers into the bowel; all of which were com- 
pletely closed, with preservation of the functions of all the organs in- 
volved." 

In a recent letter he says, with reference to his operations: 

"By examination of my reported cases, treated by this form of suture, 
you will fiud the inauguration of several new procedures in the following 
affections : 

" 1st. Urethral lacerations extending from the meatus backwards, a 
part or the whole length of the canal. By a peculiar modification of 
ray button, the catheter in these cases is supported and the closure of 



i06 AFFECTIONS OF THE VAGINA. 

the rent made complete to the meatus. (See North. Am. Med.-Chir. Re- 
view, July and November, 1857.) 

" 2d. Vesico-uterine fistulse. A mode of treatment to close the fistula 
and preserve the functions of all the organs intact. The operation con- 
sists in dividing posteriorly the anterior lip of the cervix uteri down to 
the sinus, then paring the sides of the latter and closing the wound. 
(See Case V, op. cit.) This was my first case, and here I got the idea. 
I have since performed successfully this operation in three other cases. 
In one case the sinus opened so high up in the cervical canal that the 
utero-vesical fold of peritoneum was implicated in the operation. 

"The great value of this procedure cannot be overestimated. The 
procedure of Jobert, which consists in paring the two lips of the cervix 
and uniting them by suture, is almost universally adopted by surgeons 
in this class of cases. If the operation proves successful, the men- 
strual fluid is left with no other outlet than through the small sinus 
(usually no larger than the most delicate probe) into the bladder, there 
commingling with the urine and finally escaping with it through the 
urethra. In the journals I have seen the operation is claimed as a great 
triumph. The operation is frequently performed by leading surgeons. 

" With regard to this practice I unhesitatingly condemn it. It is un- 
surgical and unjustifiable, and should never be performed. 

" 3d. Vesico-utero-vaginal fistula. An original procedure for its cure. 
(See Case VIII, op. cit., 1857.) 

"4th. Incarceration of the cervix uteri in the bladder. An original 
procedure for the disengagement of the cervix from its confined position 
and the closure of the fistula, with preservation of all the functions. (See 
Case XV, op. cit., and Cases XXVIII and XXXVIII, New Orleans 
Med. and Surg. Jour., January, March, and May, 1860.) 

" I would add here that my cases are the only ones to be found upon 
record, and I venture the assertion, without the fear of contradiction, 
that no cure will ever be effected by any other form of suture than the 
button. The mechanism of this suture is peculiarly adapted to the suc- 
cessful treatment of this rare lesion." 

I am not aware that Dr. Bozeman's operation has been objected 
to on account of want of success, for when skilfully performed all 
acknowledge its success. The chief and perhaps only objection that 
has had any effect in preventing it from general favor and practice 
is complication and consequent difficulty. This need be no objection 
if the surgeon is prepared with all the instruments now used by Dr. 
Bozeman; with them the different steps in the operation are easily 
accomplished. He requires no assistance during the operation, a con- 
sideration of no small importance. 



RECTO-VAGINAL FISTULA. 107 

JEntero-vesical Fistula. 

Occasional instances occur in which from cancerous degeneration 
of the tissues of the bladder and intestinal canal lying in contact they 
become adherent, and afterwards perforated in such manner as to 
permit tlie discharge of the excretions of one organ into the other, 
thus making an entero-vesical fistula, with the urine passing into the 
intestine and out at the anus, and causing what urine passed from 
the urethra to be mixed with foeces. The author had for several 
months under his care a recto-utero-vaginal fistula. This condition 
was caused by perimetritic inflammation. The abscess perforated the 
bladder, uterus, and rectum, and the escape of faeces as well as urine 
was observed from all these cavities. The fistulous openings were 
small and must have been tortuous, as these excretions escaped in 
very small quantities. The patient, a young girl, died of tubercular 
consumption after having lived in this miserable state eighteen months. 

Entero-vaginal Fistula. 

This is of two kinds, colono-vaginal and recto-vaginal. The former 
is very rare, and is caused by malignant ulceration or grave perime- 
tritis. The inflammation, when sufficiently severe to cause commu- 
nication between the vagina and colon, usually extends up into the 
abdomen and involves the viscera in that cavity to a very serious 
extent. The suppurating cavity in this case is also large, and opens 
in one place into the intestinal canal, ^nd at another point of ulcera- 
tion into the vagina, and as the cavity of suppuration is slowly filled 
by granulations a tortuous canal is left, leading from the bowel down 
into the vaginal cavity. If the opening into the vagina can be found, 
I see no objection to closing it with the silver suture. After a long 
time these openings would probably close spontaneouly, as artificial 
will sometimes do. 

Hecto-vaginal Fistula. 

This accident does not so frequently as vesico-vaginal fistula re- 
sult from puerperal vaginitis. Stricture of the rectum, abscess of the 
recto-vaginal septum rupturing into both cavities, and accidents with 
instruments, perhaps, as often cause it. It is not so common or fre- 
quent as vesico-vaginal fistula, nor so distressing. The passage of 
the faeces, if proper cleanliness is observed, although disgusting, is not 
so productive of inflammation and excoriation as urine, and their dis- 
charge may be controlled by appropriate fixtures. A cure is also 



108 AFFECTIONS OF THE VAGINA. 

more easily accomplished ; indeed, it is often spontaneous. As the 
contents of the bowels pass intermittingly, and. when in coatact with 
the raw surface, do not irritate it considerably, the ulcer has time to 
contract, and healthy granulations, in a good state of the general 
health, is the result. 

The symptoms and diagnosis of this fistula are so obvious that I 
need not dwell upon them ; but we sometimes meet with cases where 
the opening is so small and tortuous, that great patience in the use 
of the probe will be required to satisfy ourselves as to its position and 
direction. The injection of water into the rectum while the parts 
are under inspection will generally clear up all doubts. 

Treatment. 

If we are associated with these cases during the ulcerative condi- 
tion, we mav conduct them to a cure with some ceitainty. and. per- 
haps, more readilv than after the edges of the opening have cicatrized. 
The important items of treatment at such times are : 1st. Proper at- 
tention to the bowels ; 2d, Great cleanliness ; and 3d, ^Maintenance 
of healthy granulations until the contraction obliterates the opening. 
The bowels should be kept quiet as much of the time as possible. 
To accomplish this, the diet should be concsntrated. and nourishing 
in character; beef essence, milk, eggi^, crackers, coffee, or tea, and if 
necessary on account of debility, wane, or medicinal tonics ; and if 
the bowels have a tendency to move, opium in such quantities as will 
restrain them. Every four or five days a gentle alterative, say three 
grains of blue pill, followed by a saline cathartic : after the bowels 
have moved from this, the opium may be given to restrain them for 
four or five days again, and so on until the opening is closed. During 
this treatment there should be frequent injections of water into the 
vagina. The part should be examined with the speculum everv dav, 
to see that the edges remain raw. ^'here there is any tendency 
to cicatrize, the edges may be freely touched with pure nitric 
acid. If the cure is protracted, the acid should give place to the 
actual cautery. Toward the last, as the opening becomes small, especi- 
ally if it is tortuous, a piece of twine, or what is perhaps better, a 
silver or iron wire, may be passed through it, and the ends brou2:ht 
out through the anus and vagina. If the case is chronic and the 
opening small, the application of the acid may be made everv day 
until the edges are denuded, and then the same course followed as 
above directed. Of course, these applications must be made through 
the vagina with a speculum that completely exposes the part touched. 



RECTO-VAGINAL FISTULA. 109 

If the place Is large and chronic, we shall very nuich shorten the 
process of cure by an operation similar to that for vesico- vaginal fistula. 
After having thoroughly evacuated the bowels, the patient may be 
placed in the lithotomy position, and exposing the parts to a strong 
light, the perinseum may be retracted by the rectangular speculum 
blade of Sims, while the vulva is held open by assistants. The 
edges are then to be pared thoroughly, and the aperture closed with 
silver sutures. The bowels will require the use of from two to four 
grains of opium daily to keep them quiet. They should not be allowed 
to move for ten days, when a saline cathartic should be given, and 
after it has operated well, the stitches removed. During the time be- 
tween the operation and the removal of the stitches, the patient is to 
remain quiet in bed, and have injections, per vaginam, of tepid water 
with soap, twice a day. If by this operation there is imperfect closure 
of any part, the treatment recommended for recent cases will suffice 
to complete the cure. Even these larger-sized fistulas are sometimes 
cured by the caustic acids, the actual cautery, or tinct. lyttse ; but it 
takes a longer time, and is attended with more pain and annoyance. 
The operations on these fistulfe will be greatly facilitated by having 
the breech of the patient projecting somewhat over the end of the 
table. 



CHAPTER VI. 

MENSTRUATION AND ITS DISORDERS. 

Several conditions are necessary to the healthy performance of 
the functions of menstruation. 

1st. The ovaries must be present, and sufficiently healthy to pro- 
duce ova. 

2d. The uterus must be sufficiently perfect, anatomically and 
physiologically, to be the medium of elimination. 

3d. A certain, but not as yet very well-defined, state of the blood 
and nervous system must exist. 

These are, probably, not all the conditions necessary to perfect 
menstruation ; but they are the obvious and undoubted ones. 

The uterus, by virtue of the conditions upon which menstruation 
depends, is naturally a hgemorrhagic organ ; and it is in consequence 
of its anatomical and physiological peculiarities that the ordinary and 
frequently acting causes of uterine haemorrhage are rendered so potent 
and effective. 

The more obvious phenomena of menstruation are doubtless the 
result of a definite reflex nervous influence exerted by the ovaries 
upon the uterus. Although this influence is more distinctly mani- 
fested in the great hypersemia which precedes the occurrence of the 
cata menial discharge, and the changes in the utricular glands and 
mucous membrane of the womb, yet it is unquestionably constant in 
its action and parallel to that which presides over the motions of the 
heart, the arteries, and the alimentary canal. Generated in the nerv- 
ous apparatus of the ovaries, and contemporaneous with the changes 
called ovulation in those organs, this influence is probably conveyed 
by afferent nerves to the genito-spinal centre (the existence of which 
was first established by Budge, of Greifswalde),* or to some other 
reflecting ganglion, whence it is sent back to the uterus, giving rise 
to a wonderful series of tissue changes during the month. Some of 
these changes have been lucidly described by Dr. John Williams, in 
the Obstetrical Journal of Great Britain and Ireland, and by our 
own talented young countryman. Dr. Engelman, in his recent essay 

* Ueber das Centrum genito-spinales des N. syrapatheticus. Virchow's Archiv 
f. Path. Anat. und Klin. Med., Band xv, S. 115-126. 



PUBERTY. Ill 

upon the subject, published in the American Journal of Obstetrics. 
These changes are aptly termed by Aveling, nidation and denidation. 
A few days before the menstrual flow makes its appearance, the 
whole uterus, and especially its mucous membrane, becomes greatly 
hypertrophied and very vascular; when the discharge begins, the 
membrane is invaded by fatty degeneration. This process is so rapid 
that, in four or five days, the entire mucous membrane disappears, 
leaving the muscular structure of the inside of the uterus exposed, 
while some remnants of the utricular glands are left, and found en- 
tangled among the denuded fibres. As soon as the monthly flow 
ceases, a reproduction of the membrane is commenced, and it con- 
tinues to grow until at the end of twenty-eight days its menstrual 
maturity is attained. Accompanying these changes in the cavity of 
the uterus are others equally remarkable, affecting all the other tissues 
of the organ. The bloodvessels become enlarged, and circulate an 
increased amount of blood ; the fibrous tissue is developed beyond its 
intermenstrual condition ; while hypersesthesia indicates extraordi- 
nary nervous endowment. In fact a true hypertrophy of the uterus 
occurs. During the discharge, the process of involution reduces the 
organ to its sniallest dimensions, and the haemorrhage ceases. The 
culmination of this hypertrophy in the discharge of blood from the 
uterus is doubtless not merely an accompaniment, but a consequence 
of the breach of capillaries in the mucous membrane. These of course 
are physiological phenomena, but they strongly resemble pathological 
conditions, and would be so considered in any other organ in the 
human economy. Moreover, the dividing line between health and 
disease in uterine haemorrhage is as difficult to trace as that between 
sanity and lunacy.* 

Puberty. 

Puberty is the period at which the development of the human 
female renders her capable of childbearing. 

" An immense revolution takes place in the organization of the young 
girl. To her thin slender form succeeds a round and graceful contour. 
Her step, uncertain and hesitating, becomes firm and animated. The 
sweet and vivacious expression of her eyes evince the ardor with which 
she is endowed. Changes no less remarkable take place in the system. 
The chest, narrow and compressed, becomes expanded and full. The 
lungs act more freely, the heart, more developed, throws the blood with 

* The Causes and Treatment of Non-puerperal Haemorrhage of the Womb, Inter- 
national Medical Congress, Philadelphia, September, 1876. 



112 MENSTRUATION AXD ITS DISORDERS. 

more energy to the remotest parts of the vascular system. The areolar 
tissue is increased in quantity, fills up depressions and rounds out angles, 
making those graceful curves in the form that constitute female beauty. 

Of all the organs that feel the influence of puberty the uterus and its 
appendages are the most aflected by it. In girlhood of small volume, 
at this period, the uterus, the ovaries, Fallopian tubes, and the breasts 
become greatly developed. The bones and muscles partake in the gen- 
eral development. The moral qualities of the girl are no less the subjects 
of change. The young girl, before a mere child in her tastes, inclina- 
tions, and desires, experiences a complete metamorphosis. Restless and 
pensive, she does not know whence come the novel thoughts that agitate 
her mind ; all her impressions are pleasurable ; she is penetrated by a 
glowing fervor ; an unaccustomed pruriency pervades the organs of 
generation. The most important phenomenon of puberty, its indispen- 
sable accompaniment, that which transforms the young girl into a 
woman, the first menstrual flow, manifests itself." 

This is a translation of the description given by Brierre de Bois- 
mont in his Treatise on Menstruation. It is a true contrast between 
girlhood and womanhood. This change is not attained in an instant, 
but is the work of years, and the development, instead of always 
being regular, steady, and equable, is in many instances quite irregu- 
lar, unsteady, and unequal. Imperceptibly (comparing short periods) 
the lithe, muscular, bony, and angular form of the girl is lost. The 
bones of the pelvis, the lower extremities, and chest expand and grow, 
but no faster than during some other periods of girlhood; and the 
uterus, ovaries, and Fallopian tubes assume their places and acquire 
their size gradually. At ten years, perhaps, down is observed on the 
pubis, but does not become well-grown hair until seventeen or 
eio^hteen. In from four to eio'ht vears usuallv these chancres are 
complete. Xor does the form assume the becoming loveliness of a 
mature maiden immediately at the time the menses are first produced. 

The general and even the genital development is not complete for 
years after the first effusion of blood. A description which portrays 
anything but this gradual change is fanciful and misleads the student. 
TJje sentiments and mental habits of the o-irl when she first becrins to 
menstruate are still childish and imperfect compared with what they 
become after the completion of her first change of life. Xor do I think 
it any more correct to say that the changes in the genital organs bring 
about all the attributes that accompany their development; they are 
merely contemporaneous with the other and part of the whole. 

The development of the body generally, and of the sexual svstem 
to a perfect state, usually proceeds together, and ought to be com- 



PUBERTY. 113 

plete at the same time and in the same degree. But these conditions 
do not always obtain. Occasionally the frame and all the organs but 
those belonging to the genital system are developed into vigorous 
womanhood, while the latter do not assume the size and energy neces- 
sary for the establishment of the sexual functions ; or what is per- 
haps a more frequent condition, the individual is physically undevel- 
oped otherwise, but possesses great sexual activity if not vigor. In 
these, the general organization is feeble and imperfect, and incapable 
of meeting the requirements of womanhood, while the functions of 
ruenstruation and childbearing exist in perfection. The physiologist 
will have no difficulty in predicting in instances of this kind, the in- 
fluences that will be exerted by the dominant sexual organs. He will 
see in advance the wreck that wdll be made of the mind, heart, lungs, 
stomach, nerves, and other organs by the overwhelming sympathies 
that must arise from the undue development of the ovaries and uterus. 

When this latter system is subordinate in development and func- 
tion to the system at large, then the full health and vigor of the indi- 
vidual wall not be disturbed by the discharge of the sexual functions. 

The circumstances by which the girl is surrounded during the 
time when these puberal changes are going on, have a great influ- 
ence upon the future health of the woman. This is the turning 
period in the life of the w^oman. She is perfected or ruined in that 
time. According to her development and surrounding circumstances 
"svill be her future pathological tendencies. 

The development required for efficiency and health, is strength of 
muscle and heart, and large capacity of stomach and lungs. And it 
will require but a few moments' reflection to remind the intelligent 
physiologist that the conditions by w-hich girls at puberty are usually 
surrounded are not the best adapted to this development. The girl 
is generally allowed to exercise in the open air in the same unrestrained 
manner that her little brothers are. She exercises her muscles as 
much as her brain, and this expands her lungs and causes her heart 
to grow vigorous, and her stomach to digest w^ell. She has no ner- 
vous ailments while such freedom lasts. 

She is, however, not more than ten or twelve years old before she 
is restrained in her childish sports. She is instructed that it will be- 
come her more to deport herself like a little lady. Which means that 
her step must be quiet, her speech less loud and energetic. She must 
appear in the street only when w^ell dressed, and must conduct herself 
as becomes a woman. She must learn to sew and draw, w4iich means 
that she sit still in a stooping posture ; or she must go to school to 

8 



114 MENSTRUATION AND ITS DISORDERS. 

sit and study in a close room with many others^ breathing foul air 
for from four to six hours a day, and when she comes home get her 
lessons or " tasks " as they are properly called. If she has any more 
time she spends it in practicing on the piano or receiving company 
in the parlor. In this round of confining duties the lungs are not 
expanded to their full extent for many days together; the circulation 
is slow because there is not action enough to require quickness and 
energy in the distribution of the blood ; the muscles become weak 
and flabby from inactivity; the nervous system is taxed by study at 
school and at home, while all the rest of the body is kept in great re- 
straint. The consequences are that debility and excitability are pre- 
dominant qualities, and the development of the lungs, heart, and 
muscles does not keep pace with the growth of the brain. If exer- 
cise is required, dancing or calisthenics is resorted to, because more 
ladylike than playing ball or running races in the open air. The 
amusements of this period of life are not less injudicious. These chil- 
dren go to see the minstrels, go to theatres, ballrooms, card parties, 
and other places, where they meet the opposite sex in such manner 
as will excite their emotional nature, thus encouraging early sexual 
dev^elopment. About this time, between twelve and sixteen, the 
lungs are confined by corsets that fit "snugly" about the chest, pre- 
venting free expansion and the easy play of the diaphragm. Other 
effects of tight lacing in early as well as later life, is to press the con- 
tents of the abdomen down into the pelvis, and prevent a free return 
of venous blood from the lower part of the body. This downward 
pressure causes an accumulation of blood in the pelvic viscera, the 
rectum, ovaries, uterus, vagina, etc., and encourages congestions and 
inflammations. 

These influences, and a long train of others similar in their effects, 
are kept up from this time forward until the girl is married, and if 
she is never married always afterwards. What is usually termed 
education is commenced too early, and falls short of its objects be- 
cause it is commenced too early. Mental culture is obtained too often 
at the sacrifice of the general health, and still more frequently at an 
expense of physical development that forever mars the usefulness of 
the woman. Physical culture should be more assiduous than mental, 
during physical growth. The mind does not mature as soon as the 
body, and mental culture should be behind physical growth instead 
of before it. Six hours' study and t\vo hours' play should be re- 
versed; it should rather be eight hours unrestrained exercise and two 



PUBERTY. 115 

hours' study. In writing the above I have very feebly portrayed 
the evils that usually surround girls at the time when the puberal 
changes are going forward. I^et any one visit our schools for girls 
of this age, public or private, seminaries or boarding-schools, and see 
the requirements, restraints, and confinements of the day; let him go 
home with them and witness their want of appetite, languor, and res- 
tiveness, and then see the training from mothers and fathers, who, in 
honesty of affection, prevent them from going out for fear of exposure 
or improprieties, and encourage them to learn their lesson or music 
to the complete neglect of their bodies, and he will be astonished that 
as many survive the ordeal as now do. More time is necessary for 
physical development than mental, and until this truth is acted upon 
our women will become steadily less capable of bearing the hardships 
of life. 

In addition to the want of balance in the development of the 
physical organization above mentioned, the circumstances of society 
often cause premature and undue development of the sexual organs. 
Girls of different ages are congregated in large schools ; the younger 
learn from the older practices and imbibe sentiments beyond their 
age, which stimulate their passions and encourage too early and too 
vigorous sexual desires. The dress, the free and easy association of 
very young people, taught to imitate their seniors, the literature easily 
accessible and eagerly sought after by them, and many other cir- 
cumstances incident to children raised in populous cities, are calcu- 
lated to bring out prematurely and cultivate the amorous sentiments 
of young people of both sexes. Opportunity is frequently offered to 
medical men of large experience to see lamentable suffering in young 
girls, the result of some of these causes. Some of the most intractable 
cases of uterine disease I have ever seen have occurred in girls under- 
going puberal development, traceable to undue excitement of the 
sexual oro^ns while attendinoj laro-e schools or seminaries for vouno^ 
ladies. During the few years in which the girl is being developed 
into the woman, she is more susceptible to morbid influences operat- 
ing upon the uterus and ovaries than at any other time in life, and 
consequently these organs should be kept as free as possible from the 
effects of all conditions which excite and stimulate them. During 
this time her education ought to be one that will keep her muscles 
occupied in the discharge of useful duties. 

This very brief summary of puberal pathology will do for a start- 
ing-point in the consideration of the disorders of menstruation. 



116 AMENORRHOEA. 

I shall consider the disorders of menstruation under four different 
divisions : 

1st. Amenorrhoea. 

2d. Menorrhagia. 

3d. Dysmenorrhoea. 

4th. Misplaced menstruation (Metatithmenia). 

Under these four heads may be included all the deviations met 
with in ordinary practice. It is usual with authors to make only 
three distinct divisions. My fourth division is spoken of by those 
who have described it as uterine hsematocele, hsematoma, etc. ; but 
I shall give what I consider good reasons for classing it under the 
general head of menstrual disorders. 

In the march of pathological science it will not be surprising if, 
before long, these terms are entirely dropped from the category of 
disease, and these derangements mentioned as symptoms or errors of 
function under the circumstances in which they occur. All patholo- 
gists agree that they are only symptoms, and teach students to look to 
the diseases whence they emanate as the proper objects of treatment. 
The subject is not sufficiently clear, however, to do this now, and it 
is convenient yet to employ these terms as proper heads under which 
to group the various phenomena attending them. 

AMENOEKHCEA. 

Amenorrhoea means simply the absence of menstruation, and may 
appear under several different circumstances. 

1st. Menstruation may never make its appearance. 

2d. After having occurred it may cease, or, as the terra is, be 
"suppressed;'^ and, again, this suppression may be suddenly brought 
about and attended with 'acute symptoms, and hence properly be de- 
nominated acute suppression ; or it may not be attended with acute 
symptoms, and may last long enough to be called chronic. 

3d. I think it right to consider deficient menstruation as suppres- 
sion, although but partial. This partial suppression assumes two 
forms, viz., infrequency, when the intervals are uncommonly long; 
and scantiness, the return being regular, but the quantity of the dis- 
charge much less than it should be. Or there may be both scanti- 
ness and infrequency. 

4th. The menses may be retained in the cavities of the uterus or 
vagina, or both, after having been effused. This retention is very 
different in many respects from the suppression, giving rise to quite 



CAUSES — SYMPTOMS. 117 

a different set of symptoms, and requiring a separate sort of treat- 
ment, agreeing with it only in the non-appearance of the blood 
externally. 

Pathology and Ilorbid Anatomy, 

The pathological states upon which the symptom amenorrhoea is 
based are very numerous, and sometiuies inscrutable. The more 
obvious are the following: Congenital absence of the uterus or ova- 
ries, or both; congenital or acquired atrophy of these organs; acute 
or chronic disease of the uterus and ovaries. The general conditions 
causing it are ancemia, cachexia^ pregnancy, and nursing, serious dis- 
eases of any of the vital organs or nervous system, and occlusion of 
some part of the genital passage. 

Symptoms. 

The local symptoms wdiich attend the absence of the menses will 
differ according to the conditions which give rise to it. In acute 
suppression w^e shall have signs of great congestion, or inflammation 
of the uterus. The patient, after commencing to menstruate, being 
subjected to the causes necessary to suppression, such as the partial 
or general application of cold, is seized w^th pain in the back, hypo- 
gastric region, and hips, attended with a sense of chilliness more or 
less intense. These symptoms are usually succeeded by febrile reac- 
tion, headache, pain in the limbs, general languor, white tongue, and 
a persistent pain of varied severity in the region of the uterus. There 
is, in this state of things, as there seems to be, inflammation of the 
uterus and ovaries. The symptoms may subside, and generally do 
in a very few days, leaving more or less local discomfort in the pelvis 
and neighborhood. At the next menstrual period, if the uterus is 
not much diseased, and the system not greatly deranged, the blood is 
effused, but seldom with the same naturalness in quantity, quality, 
and painlessness as before; there is often more or less pain, which is 
manifested henceforth at each successive period. 

At other times the discharge fails to show itself after having been 
thus suppressed, and the case becomes chronic, lasting an uncertain 
length of time. When this is the case, the non-appearance is likely 
to be attended by chronic inflammation of the uterus and ovaries, as 
the result of the acute attack, and the morbid effects brought about 
by uterine sympathies derange the stomach, bowels, liver, in fact all 
the chylopoetic organs, to such a degree as to render chymification 
or chylification imperfect. Sanguification will be thus vitiated, anae- 



118 AMENORRH(EA. 

mia or cachexia results, and the patient becomes broken down and 
"miserable." We cannot but see in this catenation of circumstances 
the complicated effects resulting from inflammation of the uterus. 

Should the suppression be primary, — by this I mean to say, should 
the menses never have made their appearance, — the girl, if old enough 
and sufficiently developed, will suffer differently. And there is very 
nearly, if not quite, the same set of'symptoms present in cases where 
they have made their appearance imperfectly in quantity and quality, 
or for a few times, and then ceased. The patient suffers under the 
symptoms of imperfect sanguification : inability to exercise, palpita- 
tion of the heart, shortness of breath, torpid liver and bowels, want 
of appetite, or an appetite for improper food at improper times, de- 
spondency, great apathy, and timidity. The surface is pale, and either 
white and translucent, or more commonly of a greenish hue. The 
sufferings are often very great and protracted, and not unfrequently 
merge into those of tuberculosis, insanity, or other serious organic 
diseases. It is not unusual, even in cases where menstruation has 
never been perfectly established, to find the patient afflicted, also, 
with symptoms of inflammation of the uterus. 

The general symptoms accompanying scanty menstruation, when 
the scantiness is the result of imperfect establishment, are very much 
of the above character, viz., those connected with ansemia, etc. But 
the scantiness and infrequency, as also the entire suppression of men- 
struation, usually depend upon organic changes in the uterus gradu- 
ally brought about by chronic inflammation. What these are we 
cannot always determine. Sometimes, however, we find the fibrous 
structure condensed until the bulk of the ora^an is smaller and harder 
than natural; at other times it is greatly enlarged, as I have verified 
by examination. The most common alteration is condensation and 
atrophy. In such instances there will, of course, be quite a different 
set of symptoms, in fact many if not all the symptoms found described 
in connection with chronic inflammation of the substance of the cervix 
and body of the uterus. I need not enumerate them here, but refer 
the reader to the article in which the general symptoms of these con- 
ditions are given. Chronic amenorrhoea, or scanty or infrequent men- 
struation, is in this way associated with the most miserable states of 
general health. 

We are not to believe, however, that the absence of the menses is 
the cause of such nervous suffering as we often see associated with it, 
but that it is caused by the condition of the uterus and other organs 



■H 



SYMPTOMS. 119 

upon which the irregularity depends. The non-appearance of the 
menses on account of the absence of the uterus is not usually attended 
with the chronic suffering I have here alluded to; ordinarily, and 
indeed in all the cases of this kind to which my attention has been 
called the patients appeared to be perfectly well. One of these pa- 
tients was thirty-three years of age, another twenty-seven, and a third 
twenty-two, ard all of them were in perfectly good health. This is 
an argument, I think, in favor of the opinion just expressed, that the 
serious and annoying symptoms arise from the pathological condition 
of the uterus, or general conditions giving rise to it. The only symp- 
toms these patients complained of at any time that seemed to be at- 
tributable to amenorrhoea were the backache, weight about the hips, 
etc., which denote the presence of the menstrual molimen. In the 
cases where amenorrhoea exists before the organs are sufficiently de- 
veloped to assume the function of menstruation, w^e often observe a 
good state of health, even after the person has attained to an age when 
the menses are expected. I have had occasion to see, examine, and 
watch for several years two cases of chronic amenorrhoea from deficient 
development of the uterus, and perhaps of the ovaries. They were 
both married. One of them is twenty-eight years of age, has been 
married nine years, has never menstruated, has no sexual desires, but 
lives happily with her husband, and desires to be like other women 
merely to have a child for him. There are no distressing symptoms 
in her case. Her breasts and uterus are developed to about the size 
in a girl of thirteen years of age. There is hair upon the pubes, the 
mons is well developed, as is also the clitoris. The other has been 
married three years, is twenty-five years old, and resembles the first 
completely. 

When tuberculosis or other serious diseases cause amenorrhoea 
they are usually well manifested before the suppression occurs, but 
sometimes this symptom shows itself so early in the case that it is 
regarded as the cause of the disease instead of the effect. 

From what is said above, the reader will see that suppression is a 
symptom of the absence, imperfection, or disease of some of the organs 
of generation, or is due to some grave deterioration of the blood or 
nervous energies, and that we are to look into all the circumstances 
which attend upon it, with a view to learn the causing conditions. 
We shall not always be fortunate enough to ascertain this, and w-e 
must then content ourselves with conjecture, and a necessary uncer- 
tainty in the treatment we adopt. 



120 AMENORRH(EA. 

Amenorrhoea from Retention. 

If the retention dates from puberty the patient at the proper time 
began to experience the symptoms of menstruation. In instances 
where the retaining condition is acquired, the symptoms will be found 
to have followed close upon a severe inflammatory or ulcerated state 
of the uterus or vagina. After the retention is thus established by 
accident, the symptoms do not differ materially from those manifested 
where the occlusion is congenital. 

At first there are very moderate pains in the region of the uterus 
at each menstrual period. From month to month the pains increase 
in severity until they become excruciatingly severe. The pains at 
each menstrual epoch resemble those of labor, and cause the patient 
quite as much suffering. They are doubtless caused by the presence 
of the blood in the uterine cavity, and have for their object the ex- 
pulsion of that fluid. 

Soon after the establishment of this train of symptoms there ensues 
interparoxysmal suffering, much greater in some instances than others. 
There is a sense of weight in the pelvis and about the hips, weakness 
and pain in the back, dysuria, difficulty in evacuating the bowels on 
account of pressure upon the rectum, etc. 

There is, after the first few months, enlargement of the abdomen, 
which increases more slowly than in pregnancy. The tumor is of 
the shape and in the position of the uterus, and fluctuates obversely 
upon percussion. 

Diagnosis. 

It is not usually difficult to determine positively when there is 
amenorrhoea, and yet there may be good reason to doubt in some 
instances. It is not necessary that there should be an effusion of 
blood to constitute menstruation, for there are periodical discharges 
from the genital organs which indicate the process of ovulation, and, 
under certain conditions of the system, are more appropriate than an 
effusion of blood. I allude to a periodical discharge of mucus or 
sero-mucus. The uterine congestion is not sufficient in quantity or 
force to give rise to haemorrhage, but causes effusion of the thinner 
portions of the blood. 

We are often obliged to treat patients for a time without having 
more than their statements as a basis for our diagnosis, but fortu- 
nately, in most cases, this is sufficient. We are not justified, how- 
ever, in continuing the care of an obstinate case for any length of 
time without making an effort to verify or ascertain the fallacy of 



■n 



DIAGNOSIS. 121 

the groimds for our opinion. And, if need be, we must resort to 
physical examination. The fact of our patient being a virgin should 
cause deference, but not forbid an examination indispensable to a cor- 
rect understanding; of the cause of a condition that is destrovino; her 
life. I need only mention that suppression, attended witli acute in- 
flammation of the uterus and ovaries, will be attended with marked 
and almost invariably unmistakable symptoms. The pain, fever, 
tenderness, and sympathetic symptoms will leave no room for doubt. 
Anaemia, cachexia, nursing, etc., are obvious conditions, and will be 
easily made out by very little attention. 

Correctness in diagnosis may be attained with great certainty when 
there is physical defect in the genital organs, by proper direct exami- 
nations of them, and they should be instituted when other means 
fail to satisfy us. The presence or absence of the uterus, in most in- 
stances, can be satisfactorily determined by introducing the finger 
into the rectum and a catheter into the bladder, and approximat- 
ing them. If it is present, its thickness interposed between the 
two will prevent the finger from defining the shape of the instru- 
ment ; if it is absent, they may be mnde to touch with the interven- 
tion of the walls of the rectum and bladder. The catheter, in this 
examination, should be introduced deep into the bladder, and the 
finger as fiir up the rectum as possible. "With this precaution, there 
can hardly be a mistake. I have met with several instances of con- 
genital absence of the uterus, and in all the vaginae were absent, but 
each case presented all the external evidence of womanhood. The 
mons veneris- was perfect and covered with hair, and the clitoris, 
labia majora, and breasts were well developed. The patients had the 
demeanor of women, and assured me that their desire for the society 
of men was as great as usual, and that they experienced strong sexual 
feelino;. One of them had married, and was defendino; herself in a 
suit for divorce, upon the ground of her entire ignorance of any an- 
atomical defect in organization ; another was about twenty-two years 
of age, and submitted to an examination with the hope of having a 
correction of the physical defect, preparatory to entering matrimony. 
It is possible that the vagina may be absent while the uterus is per- 
fect in formation — the same examination will furnish us Avith proof 
— or the vagina may be occluded from defect of formation. This 
can be determined in the manner I shall presently describe. Ab- 
sence of the ovaries cannot always be determined by physical ex- 
amination, but there is generally such a complete absence of the signs 
of womanhood in these cases that we cannot long hesitate. The 



I 



122 AMENORRHCEA. 

mamm?e are not prominent, the manners peculiar to the sex, desire 
for the society of males, and sexual propensity, are absent. There 
is no hair on the pudenda, and the whole external organs are not 
developed. The signs are the same at any age. The patient at ma- 
ture age presents no more eyidence of sexuality than the little girl. 

I have very recently met with an instance of congenital atrophy of 
the uterus. The patient, although now twenty-eight years of age, 
has not menstruated, unless, as she doubtfully said, twice very scan- 
tily when about seventeen years of age. She is rather above me- 
dium size, and possesses all the characteristic appearances of woman- 
hood. She has enjoyed fair health until the last twelve months. 
For the past year she has suffered from distressing palpitation of the 
heart, which almost incapacitates her for business. She has been 
married nine years, during which time she has enjoyed sexual inter- 
course indifferently. She has no monthly pains, the signs of men- 
strual congestion, and nothing by which to know when to expect 
that function. Her mammae are about the size in a girl of thirteen 
or fourteen years, the diameter being about two inches and a half, 
with a thickness at the nipple of about three-quarters of an inch. 
The nipples are very small. The labia and mons veneris are unde- 
veloped and the vaginal orifice is narrow. The uterus coald be felt 
in its usual position or rather higher up in the pelvis, but was very 
light and small. AVhen the fingers were placed under it in the va- 
gina, and it was pressed down from above, it gave the sensation of 
diminutiveness, apparently not exceeding half its natural size. The 
ordinary uterine sound would not enter it more than half an inch. 
A probe, with an extremity about the twelfth of an inch in diameter, 
freely passed up one inch and a half. From all this, it was plain 
that the uterus was in a state of atrophy ; and I infer that the ovaries 
were so, from the absence of the nervous signs of menstruation. 

The size of the organs, as measured by the plan above indicated, 
determines, together with the history of the case, that it is congenital 
atrophy. Acquired atrophy is confined generally to the uterus, while 
congenital atrophy generally involves all the genital organs, including 
the breasts and nipples. 

I have met with a number of instances of acquired atrophy, which 
by carefully tracing their history, I could attribute to early miscar- 
riage, which it seemed to follow. And this atrophied condition, 
doubtless, was hyperinvolution of the organ after abortion. In 
looking over the menstrual history of these sufferers, there was a time 
when they menstruated normally, and the function was disturbed 
after having been thus established. 



DIAGNOSIS — PROGNOSIS. 123 

When amenorrhcea is attended by chronic inflammation of the 
uterus, a not unfrequent occurrence, the speculum and probe will re- 
veal the condition beyond the probability of making a mistake. I 
have seen the worst forms of indigestion, and very great emaciation, 
attend this conditic«i ; in fact, I have seen no other benign disease 
of the uterus produce so much emaciation as this. The patient is 
sometimes bedridden for months. In two instances recently cured 
by local treatment and proper dietetics and hygienic regulations, the 
patients had been reduced to two-thirds of their ordinary weight. 

Diagnosis of Retention. 

Upon examining the genital canal it will be found occluded at 
some point between the external labia and the internal os uteri. If 
the hymen is imperforate the vagina cannot be penetrated. If the 
occlusion is higher up, it may be found by the finger and probe. By 
introducina; the fino^er into the rectum and a catheter into the urethra, 
the bladder and rectum will be found widely separated, the catheter 
passing up close behind the pubis, and the finger being pressed 
strongly against the sacrum. The finger in the rectum will easily 
determine how near the external organs the obstruction is. 

The history, the non-appearance of the menstrual fluid, the slow 
enlargement of the abdomen, periodic jKiinfid j^CL^oxysms^ and the 
occlusion of some part of the vagina or uterine cervix, are quite 
enough to distinguish it in most cases. 

Auscultation and palpation will establish the diagnosis between 
retention and pregnancy. 

Prognosis: 

The curability of amenorrhcea will depend on the causing con- 
ditions. When occlusion of some portion of the genital canal pre- 
vents the discharge of the menses, Ave can usually, by surgical means, 
evacuate it, and establish an outlet for the future. Although simple 
and easy of accomplishment, the evacuation of a long-retained and 
considerable accumulation is always attended with hazard. In the 
first place, inflammation may foil our efforts to establish a permanent 
viaduct for the blood which may be discharged from the uterine ves- 
sels ; and in the second, this process may be so great and extend to 
the peritoneum in sufficient intensity as to cause the death of the pa- 
tient. Amenorrhcea from anaemia may be pretty surely cured; it is 
the curable variety compared with those occurring from other causes. 
When arising from inflammation, it will also generally yield to ap- 



124 AMENORRHCEA. 

propriate treatment, as the cure wholly depends upon the removal of 
the causing conditions. The cachexia which may produce amenor- 
rhoea is often entirely incurable, and, therefore, our prognosis must 
be unfavorable when they are associated. 

In cases of absence of the ovaries or uterus, ire can expect to do 
no good by treatment. Where there is only atrophy of the organs, 
we may hope that some of the ingenious contrivances to increase their 
development which our profession of the present day affords (they 
have almost all emanated from, or been perfected by, the fertile 
genius of Professor Simpson, of Edinburgh), may enable us to succeed. 
It cannot be concealed, however, that these causing conditions will 
often resist every means within our reach. To sum up, then, 
according to my observation, when suppression arises from any other 
causing condition than general anaemia, or inflammation of the uterus 
or ovaries, the prognosis is not very promising, and we should be 
cautious in promising a permanent and speedy cure. Failure in the 
function of menstruation is pretty sure to be accompanied with an 
inability for conception ; imperfection of it is, likewise^ very fre- 
quently an evidence of barrenness. This is particularly the case with 
scantiness. When menstruation is infrequent, but the function is 
otherwise perfect, the patient is often prolific. I have known a 
woman for several years, who does not menstruate more tlian three 
times in a year, and then not at regular intervals, and yet in the last 
six years she has had two children, conception following immediately 
after one of these irregular menstrual discharges. 

Treatment. 

We should always bear in mind the fact that amenorrhrea is but a 
symptom, and endeavor to amend the condition or disease upon which 
it depends. This rational mode of procedure, however, is not always 
practicable, for unfortunately, as has been more than once stated, we 
cannot in every instance ascertain precisely the condition. In such 
cases we make use of remedies, or plans of treatment, which, from 
the success that has occasionally followed their use, have gained the 
title of eramenagogues. This term signifies promoter of menstrua- 
tion. Are there any direct emmenagogues? I think, in the nature 
of things, there cannot be. To cause a flow of the menses proper, 
which depends upon ovulation for its existence, they must produce 
or promote the evolution of ova. That there are remedies and plans 
of treatment which indirectly promote the menstrual discharge I 
think there is very little doubt. In a general way we ought to con- 



TREATMENT. 125 

sider this class of remedies as producing their effects in t^YO different 
modes, one by causing the growth and production of ova, and the 
other the discharge of blood as a haemorrhage. It would be better, 
then, to say that they are oviferous in their nature in the first case 
and hsemorrhagic in the second. To the first order belong the prepa- 
rations of irofi and other mineral and vegetable tonics, nutritious diet, 
exercise in the open air, diversion of mind, travel, sea-bathing, and, 
in fact, everything wliich, by correcting derangement of the vital 
organs and generating good blood and plenty of it, is promotive of 
healthy functional action generally. To the second belong aloes, 
savin, cantharides, and any hygienic measures which determine blood 
to the pelvic organs, as foot, hip, and leg baths, sinapisms to the feet 
or legs, etc. In many instances they may very properly be combined. 

^Vhen amenorrhoea results from cold applied to the surface or 
lower extremities, or from any cause suddenly acting to suppress the 
flow, the uterus and ovaries are bordering on, if not in, a state of 
acute inflammation, and the remedies for it should be directed to the 
relief of the diseased organ or organs. The question very naturally 
arises, can we, or ought we to, do anything to cause the return of the 
flow immediately upon its suppression, and if so, what? Experience 
teaches us that if the flow can be reproduced in a very few hours 
after its suppression, before general reaction occurs, the turgid and 
phlogosed condition of the sexual apparatus may subside into a con- 
dition of health, and that this can sometimes be done by judiciously 
managed stimulation; but if the flow is not re-established in a few 
hours, we need not expect it to recur until the next period, if then, 
and it is injudicious to continue stimulation beyond a very short 
period. Then what is the proper course of stimulation? If our 
attention is called to the case within a few hours, and there is not 
much febrile reaction, we may very properly direct a hot bath to the 
whole person of the patient below the waist for half an hour. The 
patient should then be put in bed, and large sinapisms placed upon 
the inner portion of the thighs and hypogastrium, and allowed to 
remain until a strong rubefacient effect is produced, when they may 
be removed, and the whole replaced by a hot linseed-meal poultice. 
While these measures are being accomplished, we should administer 
copious draughts of some kind of warm tea. I cannot approve of 
the gin-slings or toddies given so freely under these circumstances; 
thev often do harm bv their excessive stimulation, reuderincr the in- 
flammation a fixed evil. 

Should the flux not return in twenty-four hours from the time of 



I 



126 AMENORRHCEA. 

suppression, it would be unreasonable to expect and injudicious to 
continue treatment to cause it to do so. It then remains for us, if 
possible, to remove the phlogosed condition of the organs, so that 
thev mav be in a state to resume their functions at the return of the 
next ensuing menstrual period. 

It will be found, I think, that for the first month, m case of an 
acute suppression, especially in plethoric patients, the most successful 
course of treatment will consist in moderate antiphlogistic and altera- 
tive means, kept ap steadily. The one I have ordinarily followed 
consists of counter-irritants to the hypogastric region ; the hip-bath 
twice a day of tepid water; six to ten grains of blue mass every third 
night, to be followed in the morning by a seidlitz powder; and ab- 
stinence from all stimulants and highly seasoned food. If, however, 
the suppression continue beyond the second period after the suppres- 
sion, it may be attended with chronic inflammation, with or without 
general anaemia, etc.," and will come under some of the conditions 
hereafter to be considered. 

Ameuorrhoea connected with chronic inflammation of the uterus or 
ovaries may be treated as I have elsewhere directed those affections 
to be managed. I think that it is not very common for suppression, 
in the chronic form, to depend upon inflammation alone. More fre- 
quently the causes of ameuorrhoea exist in the condition of these 
organs that remains after inflammation, such as condensation of 
fibrous tissue, either with or without atrophy. The same treatment, 
with little variation, is applicable to both. I shall have occasion to 
detail the treatment in speaking of atrophy and want of development. 

Another condition which succeeds inflammation of the uterus and 
ovaries, after an acute suppression, is anaemia. For there certainly are 
cases in which an impoverished state of the blood succeeds an acute 
suppression, and in turn prevents the re-establishment of the flow. 
A tonic, roborant treatment, applicable to anaemia arising from other 
causes, may be instituted, if need be, even before the inflammatory 
condition of these orgaas has entirely subsided. Perhaps a little more 
attention to alteratives, in connection with the tonics, is necessary in 
this class of cases. When anaemia is the primary condition upon 
which ameuorrhoea depends, it will almost always be found depen- 
dent upon some preceding affection. Indigestion, connected with a 
slow or depraved state of the secretions of the alimentary canal, often, 
by preventing the introduction of nutritious elements into the blood, 
induces anaemia. This condition arises, for the most part, in one of 
two ways, — either the nervous energy necessary to the sustenance of 



TREATMENT. 127 

tliP functions is diverted to other objects, as mental training in the 
school-girl, or tlie circulation in the abdominal organs is too sluggish 
on account of sedentary habits, as with the sewing-girl. Sometimes 
want of exercise and too great a tax upon the brain from studies, 
anxiety, etc., co-operate in the same individual. Anaemia may be 
produced by a great variety of causes besides those above-mentioned, 
but, according to my experience, these are far the most frequent. I 
would not hav^e the reader believe, because I have given the school- 
girl and the sewing-girl as instances of amenorrhoea, that they are 
the only persons in whom the same character of causes operate in the 
same way. Very many fashionable young ladies, who might enjoy 
the blessings of relaxed, diverted, or healthily employed minds, and 
appropriate and enlivening exercise, become anaemic from sheer lazi- 
ness and the nervous anxiety connected with envy. 

Bearing in mind, then, the causes of indigestion and anaemia, we 
must, first of all, thoroughly revolutionize the habits and circumstances 
of the patient, making plenty of outdoor exercise one of the main 
conditions. Riding in a carriage is not outdoor exercise for these 
patients; they must ride on horseback, or, what is very well, walk, 
run, and romp. An excellent sort of diversion for the mind is occu- 
pation in domestic duties, making beds, sweeping, cooking, washing, 
caring for and attending children, etc. The mind and body are both 
employed in a varied and diverse manner in these household duties, 
and it will be found that exercise both of body and mind is most 
profitable as it is most diverse and varied. While it is true that 
some kinds of exercise, as walking or riding, may be made to call 
into play a great many muscles, yet the whole routine of duties pre- 
senting themselves in the business of housekeeping, by personally 
doing the work, is more beneficial than all others devised. This 
lesson is taught by the contrast between the young mistress and her 
servant. 

In addition to the adoption of a more rational course of habits for 
the patient, much may be done by the judicious use of medicines. 
Almost invariably the tonics must be preceded by, or accompanied 
with, alteratives and laxatives. The stomach will no more recognize 
and respond properly to a tonic that is intrduced into it until pre- 
pared by correcting the secretions, quickening the gastric circulation, 
and unloading the bowels, than it will digest food under similar cir- 
cumstances. The alteratives suitable, generally, are mercury in some 
form, taraxacum, and turpentine. When the bowels are torpid, the 
stools dry and of unnatural color, particularly if the color is light, 



128 AMENORRHEA. 

from three to six grains of blue mass, given every third night, and 
followed next morning by a seidlitz powder, or sufficient sulphate of 
magnesia to cause one or two evacuations, is an admirable alterative. 
Ten grains of good extract of taraxacum, with a minute quantity, 
say the twentieth of a grain, of bicliloride or biniodide of mercury, 
three times a day for two or three days, generally does very well. 
The mercury should not be given with tlie taraxacum longer than 
three days, and then intermitted for a week, but the taraxacum may 
be given steadily for weeks. An excellent alterative for the stomach 
is Venice turpentine. Ten grains three times a day after eating, on 
sugar, alternated or given with some of the mercurial preparations, 
proves often of great service. I cannot but mention the compound 
confection of black pepper, made in imitation of Ward^s paste, as 
having frequently an excellent laxative and corrective effect on a 
weak state of the stomach accompanied w^th constipation. I have 
known it to cure some of the most obstinate cases of constipation 
attended with anaemia. 

If there is not scantiness of secretions, but slowness of peristaltic 
movement, we ought to depend on rhubarb and aloes. The com- 
pound aloetic pill is a good preparation. In the selection of tonics 
we should bear in mind the difference between the stomachic and 
blood tonics. Iron is, perhaps, the only direct blood tonic, while 
there are a great many articles that act as stomachics. Almost all 
the bitter vegetables ranged under that head in the books are useful 
under certain circumstances. The stomach tonics, by improving di- 
gestion, are indirectly blood tonics, so that they are sometimes all 
that are necessary. In many instances, too, the stomach must be 
prompted by the bitters, or other stomachics, before it will absorb or 
assimilate iron. The bitter may precede the iron, or be administered 
simultaneously with it. It is sometimes convenient and profitable 
to combine the alterative and stomach tonic. A mixture of this 
kind, often used, is the compound tincture of cinchona, with bichlo- 
ride of mercury dissolved in it. The tincture of gentian, or colomba, 
answers very well compounded with mercury. Extract of gentian 
and Quevenne's iron compounded in a pill produce good results on 
the anaemic patient. If we understand the principle that governs the 
treatment in such cases we may readily find the means to accomplish 
our ends, by alteratives, stomach tonics, and blood tonics. 

The cachexise, several of which interfere with the regularity of 
the function of menstruation, must be treated as if the menses were 
present in their normal quantity, and in these cases the amenorrhoeal 



TREATMENT. 129 

complication is of no importance, hence special efforts to restore the 
flow are injudicious, and in most cases injurious. 

In cases of defective nervous energy we may expect benefit from 
the direct application of electricity to the uterus, or to the nerves that 
supply it. In a paper, recently read before the New York State 
Medical Society, by A. D. Rockwell, M.D.,* I find the following 
statement : 

" Araenorrhcea is a symptom that yields, perhaps, more readily to some 
one of the many forms of electrization than to any or all other methods 
of treatment. In cases dependent on, or associated with, general debility 
general electrization is of course indicated ; but where all external efforts 
have been fruitless, internal electrization is not infrequently followed by 
an immediate and satisfactory flow." 

He gives a case as illustrative of the efficacy of his method of 
performing local electrization : 

"I introduced a cup-shaped metallic electrode to the uterus, so that 
the OS was completely surrounded, and applied the positive pole firmly 
against the abdomen immediately above the pubes. The current, which 
was of considerable strength, I reversed rapidly a number of times during 
the seance, and on the following day repeated the application. In less 
than six hours after making the second attempt, slight signs of returning 
menstruation were manifest, and steadily increased until, as regards 
quantity, the flow was quite natural. The patient was immediately re- 
lieved of all her distressing spasmodic symptoms, and at the present time 
(three weeks having elapsed since the treatment) still remains free from 
them." 

Query. Was this menstruation or metrorrhagia? 
Dr. Parvin, in the same journal, says : 

" The positive electrode passed into the uterine cavity, the negative 
applied to the hypogastrium, gives oftentimes a very prompt success in 
inducing a sanguineous discharge from the uterus; but in order that 
such result should follow, this means should be used only at a time when 
the other phenomena of menstruation manifest themselves, the flow only 
wanting." 

The faradic is the form of electrization recommended by both 
these gentlemen. 

In patients well developed in most respects, whose genital system 

■^ American Practitioner, May, 1872. 



130 AMENORRHCEA. 

is deficient, the menses cannot be produced unless these organs grow 
and become more active. Anything that will stimulate these organs 
will occasionally bring this result about. Wedlock is a remedy some- 
times. The indulgence in society, and the recreations of it, in com- 
pany with men, sometimes, through the moral faculties, stimulate the 
genital organs towards development. The stimulus thus afforded by 
society is one of the beneficial effects resulting from the change of 
habits in young girls who go to boarding-schools until sexually 
dwarfed by confinement to the uninteresting society of their own sex. 

Professor Simpson has recommended an instrument, which he calls 
an "intrauterine pessary," to bring about this development. It is 
equally applicable to cases of atrophy of the uterus arising after the 
menses have been established. I have had occasion to use it, and am 
now employing it in the interesting case to which I have alluded 
above. It is theoret'wally better, I am afraid, than it will be found 
pradicaUy; yet there is no doubt much good may be done by it. 
The object of the intrauterine pessary is to be the medium, or gene- 
rator^ rather, of galvanism, to stimulate the nerves of the uterus. 

Both of these effects are promotive of uterine haemorrhage, if not 
of correct menstruation. They are necessary to the development of 
an atrophied uterus, whether congenital or acquired. But this in- 
strument is recommended and used in obstinate cases of amenorrhoea, 
where there is- no apparent deficiency in the size and development of 
the organs concerned. It is in this class of cases that most may be 
effected by it, and yet it sometimes entirely fails to produce any effect. 
To do good in the cases of atrophy and want of development it should 
be used continuously. Where the development is good, I am inclined 
to think that the pessar}^ will do more good by using it intermittingly. 
In these cases we may introduce the instrument and allow it to re- 
main one week before the time of the expected period, and then, after 
the time is passed, remove it, and again introduce it at the proper 
time. We should remember that we cannot use an instrument of 
the same size in all cases. In the uterus that is much atrophied it 
would be violence to use an instrument that is applicable to a fully 
developed organ. In the former we must have an instrument that 
will pass into it easily, and in a couple of months use one larger; 
and after the lapse of a similar time make another one still larger, 
etc., until development is complete. The instrument is made of cop- 
per and zinc, and consists of a stem and bulb. Tlie bulb is hollow, 
in order to be light as possible, flattened, and oval in shape, one inch 
long, three-quarters of an inch wide, and half an inch thick. It 



TREATMENT. 131 

should be perforated through its thinnest diameter by a hole two- 
twelfths of an inch in diameter. Into this perforation the stem is to 
be inserted. The stem should be two inches long for a uterus not 
atrophied, and as much less as is necessary, in the judgment of the 
attendant, when atrophy has taken place. It should be hollow and 
light like the bulb. The bulb, and one inch of the stem next the 
bulb, is made of copper, the extremity of the stem of zinc. This 
completes the instrument as made and used by Professor Simpson. 
I find, in some instances, great difficulty, if not an entire impracti- 
cability, in wearing it, on account of its tendency to fall out. Some- 
times, too, the galvanic stimulus is not sufficient. On these accounts 
I have made an addition to it, which, I think, adds to its efficiency 
as well as security of position. This consists of a zinc ball, about an 
inch in diameter, attached to a copper rod four inches long. The 
ball is introduced into the vagina after the intrauterine pessary has 
been introduced, while the stem is attached to a framework outside 
the pelvis to keep the whole in position. As will be seen by a study 
of this apparatus we have quite a galvanic battery, the copper rod 
reaching from the framework of zinc outside to the zinc ball inside, 
this last lying in contact with the copper bulb of the pessary, etc. 
If we do not desire any galvanism in the case the whole apparatus 
can be made of copper. Made in this w^ay the instrument is quite 
efficient. The young physician or student may be embarrassed in 
his attempts to introduce the pessary without a little consideration. 
The plan I have found most convenient is, to expose the os uteri by 
means of the quadrivalve speculum; secondly, to secure the pessary 
by inserting a piece of whalebone, properly shaped, in the perforation 
in the bulb; thirdly, thus raounterl, to insert the stem, and w^ith great 
gentleness urge it forward to its full length, or until it is arrested by 
the contracted internal os uteri or the end touching the fundus. If 
this arrest occurs the instrument is either too large or too long, and 
must be replaced by one more suitable in this respect. After the 
pessary is inserted we may withdraw the speculum, and, if necessary, 
apply the ball and external framework above described to keep it in 
position. All this direction does not include a fact which should ever 
be borne in mind by the student, viz., that sometimes the instrument 
is utterly intolerable; and, at others, a good deal of address and pa- 
tience is required to habituate the parts to it. The patient should be 
forewarned that pain and inflammation are the possible effi^cts, and 
that she must inform us should they be considerable. There is always 
some pain, sometimes a great deal. When the irritation is too severe 



132 AMENORRn(EA. 

the instrument must be removed, quietude observed, and, if necessary, 
anodynes, and even antiphlogistic treatment must be resorted to, to 
remove the symptoms. After all these have subsided it may be again 
introduced. A little perseverance and care will render most cases 
tolerant of its presence. During the time the instrument is used 
the vagina must be thoroughly cleansed, at least twice a day, with 
tepid, warm, or cold water, and fine soap, used as injections. 



CHAPTEE VII. 

MENOEKHAGIA AND METRORRHAGIA. 

H.EMORKHAGE Occurring at the time of menstruation beyond the 
usual quantity is menorrhagia. Haemorrhages occurring at other 
times do not belong to this denomination, but are called metror- 
rhagia. Often both metrorrhagia and menorrhagia occur in the same 
individual, which depend upon the same conditions of the system or 
reproductive organs, and are alike symptomatic of some local or 
general disease. 

It is not difficult to understand that an exaggeration of the hyper- 
semia, or an unusually rapid disintegration of the uterine mucous 
membrane, would cause more than a normal amount of flow, nor 
that a want of accordance in time might be followed by the same 
result. Indeed most cases of uterine haemorrhage are traceable to 
conditions which disturb the equilibrium of these phenomena. The 
causes which thus act are varied and numerous. 

Morbid nervous influences, which increase the discharge of blood 
from the uterus, sometimes emanate from the nervous centres, and 
hence may be properly termed centric; much more frequently, how- 
ever, they are reflected through the nervous centres from other and 
sometimes distant organs, and these last are entitled to the denomina- 
tion of reflex or eccentric nervous influences. 

Mental and emotional excitement emanating directly from the 
brain, and cerebral and spinal excitement originating in inflammation 
or functional exhaustion of the brain or spinal cord, are examples of 
centric etiological influences. Many years ago I witnessed the rav- 
ages of an epidemic of cerebro-spinal inflammation, in which uterine 
haemorrhage was of almost universal occurrence among those adult 
females who fell under its influences. 

Morbid reflex nervous influences afford a more numerous class of 
causes. First among them, both in frequency and importance, are 
those arising from abnormal conditions of the ovaries, such as con- 
gestion, inflammation, displacement, and erotic excitement. Next to 
the influence of these bodies is that exerted by the mammary glands. 
Menstruation is generally more profuse when it occurs during lacta- 
tion. The effect of mammary irritation in causing congestion of the 



134 MENORRHAGIA AND METRORRHAGIA. 

uterus, and thus promoting haemorrhage from it, is well illustrated 
by the familiar fact that sinapisms or blisters applied to the breasts 
will often cause metrorrhagia. Vesical irritation, or inflammation, 
which gives rise to tenesmus, rectal irritation, as from the presence 
of haemorrhoids or ascarides, and dysenteric inflammation, through 
the reflex influence which they exert upon the uterus, are generally 
recognized causes of uterine haemorrhage. Among other reflex 
causes may be mentioned certain forms of indigestion, hepatic con- 
p-estion and inflammation, and some of the disturbances of the small 
intestines, as may also strong impressions upon the cutaneous surface, 
as from cold, or from the long-continued application of heat in warm 
climates and seasons. 

All of these last-mentioned causes I think act through the reflex 
system of spinal nerves, and perhaps also through the agency of the 
sympathetic ganglia, which perform a reflex function between the 
viscera. The morbid effects of the various reflex nervous impressions 
are rendered more effective and intense by the presence of such 
uterine diseases as predispose to haemorrhage by increasing the vascu- 
larity of the uterus. 

Many pathological conditions which conduce to the production of 
uterine hsemorrliage, independently of direct nervous influence, act 
by increasing the hypersemia of the uterus. When the mucous mem- 
brane is granulated, or is the seat of inflammation, of fibrous polypus, 
or of malignant fungus, the circulation of the uterus is increased, 
and harmony in the process of nidation disturbed ; and these con- 
ditions will be accompanied by an unusual and long-continued flow 
of blood. Subinvolution, congestion and inflammation, hyperplasia, 
tuberculosis, cancerous and fibrous deposits in the muscular structure, 
and chronic and acute endometritis, in addition to preventing the 
normal deciduous changes in the mucous membrane of the uterus, 
maintain a permanent hypersemia, and thus render the womb prone 
to large losses at each return of the menstrual period. We have, in 
fact, abundant reasons for assuming that chronic hypersemia, no 
matter how produced, will, by virtue of the malnutrition connected 
with it, prevent menstrual changes from being effected in an orderly 
manner, and thus render the mucous membrane more frail in or- 
ganization, and consequently incapable of resisting the force of vascu- 
lar pressure to which it is periodically subjected. 

Besides the causes of uterine hypersemia last alluded to, and exist- 
ing within the tissues of the womb, there are many other outside 
'pathological conditions acting in a different way. Some of these cause 



CAUSES OF MENORRHAGIA. 135 

venous liypertemla by mechanical retardation of the circulation, 
Avhile others give rise to both arterial and venous hypersemia by 
nutritional attraction, and others again cause arterial hyperismia 
alone, by forcing unusual amounts of blood into the organ. Among 
the most frequent and important causes of venous retardation are 
displacements and flexions of the uterus — procidentia, retroversion, 
and retroflexion — the former by stretching the veins and rendering 
their course more tortuous, the latter by twisting them, and thus 
lessening their calibre; exudations into the cellular tissue and peri- 
toneal pouch, from cellulitis and local peritonitis, and effusions of 
blood in the cul-de-sac of Douglas, in retro-uterine hsematocele, by 
pressing upon the veins, prevent a free return of blood from the 
uterus, and thus cause venous hypersemia. Retardation of move- 
ment in the uterine veins may also be caused by obstruction to the 
venous circulation quite remote from the womb, as by the pressure 
of a tumor upon the ascending vena cava, by a loaded condition of 
the large intestine, by dislocation or enlargement of the liver, by 
obstruction to the free passage of blood through the heart from val- 
vular disease, and even by certain pulmonary affections. 

In the class of causes giving rise to both arterial and venous hyper- 
8emia may be mentioned fibrous, fibrocystic, polypoid, and fungous 
growths of the fibrous structure of tlie uterus. These all increase 
the flow of blood to and through the vessels of the uterus, both 
arteries and veins are increased in capacity, and to these changes is 
added general hypertrophy. In these cases the hypersemia of all the 
tissues is sometimes enormously great, and the losses of blood are 
proportionally large and dangerous; the haemorrhage, unlike that 
from venous, obstruction, is not checked by the emptying of the 
vessels, but continues until the arterial and cardiac vis-a-tergo is 
Aveakened by approaching syncope. 

Causes producing arterial hyperaemia alone are hypertrophy of the 
heart, general plethora, febrile excitement, and violent exercise. The 
uterine hyperajmia in these cases is caused by unusual arterial and 
cardiac pressure alone. When not attended by local pathological 
conditions, the haemorrhage in these cases is not apt to be serious. 

Other not uncommon causes of haemorrhage from the womb are 
various diseases of the blood. Among these may be mentioned 
scurvy, leucocythsemia, chlorosis, albuminuria, and syphilis. It is 
not likely that the vice in the composition of the blood is the sole 
causative influence operating in the above-named conditions. In 
scurvy, for instance, we know that the solid tissues, whether as a 



136 MENORRHAGIA AND METRORRHAGIA. 

primary condition or as an effect of the blood-changes, are diseased, 
the capillaries more fragile than natural, and, consequently, less 
capable of resisting the cardiac impulse. As evidence that the vicious 
condition of both blood and solid tissues is the cause of uterine hsem- 
orrhage in scurvy, the well-known fact may be added that bleeding 
is very easily provoked in other mucous membranes. It is the more 
likely to take place from the mucous membrane of the uterus, 
because of the great normal fluctuations in tlie circulation of that 
organ, and also because the vitiated state of the blood would nat- 
urally cause disturbance in other conditions attendant upon menstru- 
ation, especially the decidual changes. It will be seen therefore that 
the peculiarity in the operation of this variety of cause is not due to 
the presence of local or general hypersemia from retardation of the 
venous circulation, or from arterial and cardiac pressure, but is due 
to the tendency of the blood to escape through the walls of the 
vessels, and to the inability of the capillary tubes to resist the circu- 
latory force ordinarily applied to them. 

As another cause of haemorrhage from the womb, must be men- 
tioned the well-known law of the human system, to continue a long- 
established habit after the original cause is removed. This is prob- 
ably the only rational explanation of those rare uterine losses which 
are sometimes observed in pregnancy and in cases where both ovaries 
have been removed. The habit of bleeding continues after the 
ovarian reflex nervous influence has been withdrawn from the 
uterus. 

Still another rare yet very dangerous cause of uterine haemorrhage 
is that known to surgeons as the hcemorrhagic diathesis. The writer 
has seen one case in which he believes that the bleeding was clearly 
attributable to this mysterious condition, and which proved fatal. 
It was that of a young girl who died with her second menstrual flow. 

The wide range of causative conditions found connected with 
uterine haemorrhage is but an inverse exhibition of the sympathetic 
relations of the uterus. When diseased, it exercises an almost uni- 
versal pathological influence upon other organs, and, as a conse- 
quence, it is susceptible of being impressed to the same degree by 
certain morbid conditions of all important viscera. It will not be 
regarded as making an undue claim to say that the practice of gynae- 
cology requires a more thorough theoretical and practical familiarity 
with the details of all the branches of medicine than any other of the 
so-called specialties, ^ye are not prepared to treat the most common 
of female diseases without being able to scan with scientific scrutiny 



TREATMENT OF MENORRHAGIA. 137 

every organ and function of the body. Xor until we can com])ete 
successfully with the general practitioner, the surgeon, the alienist, 
and the neurologist in the therapeutic processes of their respective 
departments may we hope to exercise in the highest sense the office 
of the gynaecologist. These remarks apply with force to the comp-e- 
hension of the causes and treatuient of haemorrhages of the unimpreg- 
nated and non-puerperal uterus. 

Treatment of Menorrhagia. 

I find it quite impossible to satisfy myself as to the best order in 
which to bring forward the various measures proposed for treating 
uterine haemorrhage. Those which have for their object the removal 
of the causing conditions, properly fall under the head of curative 
means ; while those which we employ to stop the bleeding tempo- 
rarily, until the remedies of the first order have accomplished their 
purpose, seem as naturally to belong to the category of paUiative 
measures. We find in each of these divisions, however, remedies 
which act in both ways, and the palliative means are often radical 
and energetic. Notwithstanding the many obvious deficiencies in 
this arrangement, it seems to me to be the best that I can adopt. 

Palliative Treatment. 

Before entering into a detailed description of the more essential 
remedial methods of curing the various forms of hseraorrhage it will 
be profitable to consider some of the important minor measures which 
are applicable in almost all instances. As the great majority of 
haemorrhages occur at the menstrual periods, we often have oppor- 
tunities of adopting measures in anticipation of them. These meas- 
ures are sometimes calculated to entirely prevent an exaggerated 
flow, and at others to very much modify it; and in all to greatly 
promote the action of more direct remedies. The patient should ab- 
stain from all causes of local or general vascular or nervous excite- 
ment. Among these causes are mental and bodily fatigue, emotional 
excitement arising from certain social relations, sensational books, 
and the contemplation of erotic objects. The patient should also ab- 
stain from stimulating drinks and highly seasoned food; her clothing 
should be loose and cool, so that no part of the bod}" may be con- 
stricted, and the genital organs should not be too warmly covered. 
Her bowels ought to be kept regular, or rather free. The secretions 
from the skin, liver, and kidneys should be maintained as nearly as 



13S MENORRHAGIA AND METRORRHAGIA. 

possible in a normal condition, and tonics, such as arsenic, strychnia, 
and quinia, with digestible, nourishing, and unstlniulating diet, should 
be given in quantities sufficient to keep the health up to the normal 
standard. Other things which will contribute very greatly to good 
results are plenty of pure air, night and day, and moderate muscular 
exercise. Many other general directions will suggest themselves, 
which I cannot stop now to mention. 

When the time for the paroxysm has arrived, and the haemor- 
rhage has commenced, isolation, quietude, and recumbency are very 
important precautions to be enjoined. Position, indeed, may be 
made to do much good of itself. If the haemorrhage is not severe, 
mere recumbency will be sufficient; but if it is protracted, the hips 
should be elevated, and sometimes it will be beneficial to raise them 
so high as to cause the blood to gravitate to the fundus uteri, and to 
fill the whole genital canal before any of it passes out. To a con- 
siderable extent this may be made to act as a tampon. The position 
chosen to effect this object may be on the back, or upon the knees 
and chest. If the latter position can be commanded, it is much the 
best, as the reversal of gravitation is more complete. Cold and acid 
drinks, cold applications to the hypogastric and sacral regions, hips, 
and vulva, and in the vagina, are also among the remedies applicable 
to almost all cases. Many practitioners value astringents, adminis- 
tered internally, in uterine haemorrhage, but I have found so little 
benefit from them when not given with oj)ium or belladonna, that I 
seldom resort to them. Where there is much pain in the pelvis, and 
a dry state of the skin, opium and ipecacuanha are often very ser- 
viceable. Lobelia, gelsemium, digitalis, aconite, and veratrum \iride, 
may also be mentioned as very frequently applicable where there is 
vascular and nervous excitement. 

Perhaps the medicine most generally applicable in paroxysms of 
uterine haemorrhage, is ergot. In all cases of local arterial hypersemia, 
as in tumors, hyperinvolution, etc., we may expect good from its em- 
ployment. But it will generally fail to be useful when the uterine 
hyperaemia is venous, as in retroversion, pelvic infarction from peri- 
uterine effusion, abdominal tumors, etc. It will not act efficiently in 
cases of carcinomatous deposit, granulations of the mucous membrane, 
or tuberculous degeneration of the fibrous texture of the uterus. 

In the more dangerous instances of haemorrhage, these moderate 
palliative measure are not sufficient. In some, the amount of loss is 
so great, and occurs so suddenly, as to threaten the life of the patient. 
Or, if life is not in danger, the discharge may be sufficient to lead to 



TREATMENT OF MENORRHAGIA. 139 

other verv serious remote consequences. These emergencies are to be 
met bv such means as will promptly arrest the flow, and keep it in 
check until curative processes can be instituted. Fortunately this 
may be done with great certainty by mechanical and chemical ap- 
pliances generally at our command. The genital canal, practically 
closed at its upper extremity, and conveniently open at its lower ter- 
mination, admits of being impacted to an impermeable degree, and 
allows of topical applications to its whole extent. In u-ing either 
form of these topical measures, the effort should be made to a|)p]y 
the remedy as near to the bleeding point as possible. 

AVhen practicable, we may secure the best effects by employing 
the mechanical and chemical means conjointly. The mechanical 
means embrace the different forms of the tampon. Plugging arrests 
the haemorrhage by forcibly opposing the evacuation of the blood, 
and by thus imprisoning it in the smallest cavity. The blood so 
confined, coagulates, and fills the space between the tampon and the 
bleeding surface with a fibrinous clot, which also closes the mouths 
of the vessels. When plugging is skilfully perforn^ied, the relief is 
temporarily perfect, and gives us valuable time for other treatment, 
or allows the cyclical period to pass, when the hypersemia subsides. 
The chemical means consist in the use of powerful htemostatics. By 
their chemical action upon the solid constituents of the blood, they 
produce a much firmer coagulum than results from mere stasis, and, if 
applied to the ruptured vessels, seal them up with coagulated plastic 
material, while if further away the coagulum forms a chemical tam- 
pon which opposes the flow toward the vulva. Used with the me- 
chanical tampon they may be made to fill the interstices of the ma- 
terial of which it is formed, and thus solidify the whole mass. 

In the greater number of dangerous cases of the kind of uterine 
haemorrhage, the mouth of the womb is sufficiently patent to permit 
the introduction of the plugging material saturated with a htemostatic 
preparation into the cavity of the uterus. Dr. Sims's method of 
preparing the material and performing the operation of plugging the 
womb is admirable in its simplicity and efficiency. The substance 
used is the finest article of cotton-wool, saturated with a liquid com- 
posed of one part of the strong solution of the subsulphate of iron and 
two of water. After the cotton has been perfectly saturated, it is de- 
prived of the major part of its fluid by pressure, and is then allowed 
to dry until ready for use. The application is made by wrapping 
a sufficient quantity of the dried iron-cotton around a long, small 
piece of whalebone, and introducing it into the cavity of the uterus, 



140 MENORRHAGIA AND METRORRHAGIA. 

Avhen the cotton is detaclied and left there. If the hsemorrhage is 
comparatively moderate, one of these pieces may be sufficient ; if 
severe, it will be necessary to stuff the uterine cavity full. This can 
be best accomplished by having the patient placed on her side, and 
the uterus exposed by Sims's speculum. To facilitate the removal of 
this ferruginous tampon, the suggestion of Dr. J. R. Chadwick, of 
Boston, is, I think, a valuable one, viz., to wrap strong thread loosely 
around the cotton as it surrounds the whalebone. I prefer this 
method of using the haemostatic to its injection, because the shock 
from the application is much less. 

If the mouth and cervical cavity of the womb are not sufficiently 
open to permit of the introduction of this haemostatic preparation, we 
may plug the cervix with prepared sponge. The first sponge should 
be pushed through the cervix into the cavity, and up to the fundus 
uteri, so that when it expands its upper end may possibly reach and 
press upon the bleeding: point. If large enough, the cervical cavity 
will be completely filled and the bleeding effectually checked. The 
sponge should be carboHzed, and well secured, before it is introduced, 
by passing a strong piece of twine through it, from one end to the 
other. Neither the cotton nor sponge should be allowed to remain 
longer than twenty-four hours, and half of that time is usually long 
enough. After removal, the vagina may be cleansed, and the appli- 
cation repeated if necessary. I have sometimes been obliged to renew 
the sponge tampon several times in the same case, though this is not 
usually required. 

If these means are not at hand, or if the case is not sufficiently 
urgent to require plugging of the uterus, we may resort to the vaginal 
tampon. This may be made of cotton, of which pieces as large 
as pullet's eggs may be used, rolled somewhat solidly, and each 
secured with thread and lubricated with oil or lard. A sufficient 
number to perfectly fill the vagina should be prepared. The pa- 
tient should be placed on her left side, with the limbs flexed, and 
the upper one thrown forward over the other. The operator, 
standing at the back of the patient, inserts into the vagina two 
fingers of the left hand, with wdiich he draws the perinaeum well 
backward. This will open the canal so that the clots may be easily 
removed with the fingers, when, with the right hand, the cotton may 
be placed with great facility in the vagina. At first several on the 
OS and around it, and then the whole vagina may be packed solidly 
under the eye of the operator. If Sims's speculum be at hand, it 
should be used instead of the two fingers to hold back the perinseum. 



CURATIVE TREATMENT OF MENORRHAGIA. 141 

Or we may vary this according to the process described by Dr. 
Thomas iu the American Journal of the Medical Sciences for July, 
1876, page 147. After dilating the vagina, " pieces of cotton, soaked 
in ^Yater, pressed and flattened out by the fingers, each about the size 
of a very small biscuit, are pressed into tlie vaginal cul-de-sac by 
means of forceps till this is filled. Then other pieces are packed 
firmly around the cervix until only the os is visible; a smaller pad 
is then pressed firmly against or introduced within the cervical canal, 
and the whole vagina is then filled to its lowest portion." An ordi- 
nary surgeon's roller answers admirably for a plug, and may be in- 
troduced by first inserting one end, and then passing it up in short 
folds until enough has been placed in the vaginal cavity to fill it up 
compactly. In most cases, where we desire to leave the patient, the 
tampon should be retained by a compress and '^ T '^ bandage. 

When we have reason to anticipate a sudden occurrence of severe 
haemorrhage in our absence, we may instruct the patient or nurse how 
to make and apply a very safe vaginal plug. A sponge, large enough 
to fill the vagina closely, may be prepared by wetting it in a strong so- 
lution of alum, or in a weak solution of subsulphate of iron, passing 
a piece of strong twine or tape through the centre, and then wrapping 
it with tape in an elongated shape to its smallest dimensions. It 
may then be laid aside to dry. When the necessity for its use arises 
the tape is removed, and the sponge thus compressed may be passed 
without any resistance entirely into the vagina. It is soon expanded 
by the blood, and the vaginal cavity thoroughly filled. A few of these 
sponges prepared ready for instant use will enable the patient to pre- 
vent any material loss until the practitioner arrives. The plug may 
be removed by the tape or. twine whenever desired. The })lug may 
be allowed to remain from eighteen to twenty-four hours, when it 
should be withdrawn, and the vagina having been thoroughly cleansed 
w^ith carbolized water, replaced if necessary. 

Curative Treatment. 

The central nervous disorders which cause uterine haemorrhage 
will, Avhen recognized, require the treatment set forth in the various 
works upon these subjects. I need not, therefore, dwell here upon' 
the management of the spinal and cerebral inflammations and irrita- 
tions, nor upon the numerous forms of emotional excitement which 
lead to metrorrhagia. The treatment of the reflex, morbid, nervous 
influences belongs more particularly to gynaecology, and will call for 



142 MENORRHAGIA AXD METRORRHAGIA. 

all the ingenuity and varied knoTvledge taught in thnt branch of 
practical medicine. The ovarian derangements, being the more ob- 
vious and common of these may be noticed first. Oar means for re- 
placing and retaining in position displaced ovaries are verv meagre. 
The patient mtist be confined to the horizontal position, with the 
pelvis elevated as much as practicable. The knee-chest position is 
the best, and may often be maintained for a considerable part of the 
twenty-four hours. Generally the displacement is accompanied by 
congestion or inflammation of the ovary, which increases its size and 
weight. T\'hen this is the case, the treatment, in addition to position 
and quietude, recommended during the intermenstrual period, will 
consist in the use of counter-irritants, hip-baths, hot-water vaginal 
injections, and alteratives, administered internally, or applied exter- 
nally in the form of ointments, or per vaginara as suppositories, in- 
jections, etc. Among the alteratives, the muriate of ammonia will 
be found very valuable. When there is much debility, the bichlo- 
ride of mercury, dissolved in the compound tincture of cinchona, is 
among the very best. Iodine, iodide of potassium, and iodide of iron 
should also be named as efficient alteratives in these conditions of the 
ovaries. One derivative measure which I desire to mention as espe- 
cially beneficial in these cases is dry cupping over the sacrum, often 
repeated. To be effectual the cups should be large and allowed to 
remain for a long time, say an hour or more. AYhen there is much 
pain in the ovarian regions, suppositories of the extract of belladonna 
and ergot, once or twice daily, will not only relieve the pain, but will 
do much towards allaying the inflammation. 

When haemorrhage occurs in a nursing woman, if it is of sufficient 
gravity, the child should be weaned. At the time of the paroxysm, 
if the breasts are tumid and tender, cold may be applied to them to 
relieve both the uterine haemorrhage and the mammary congestion. 
These patients require invigorating measures in connection with the 
local treatment of the breasts. 

The vesical or rectal tenesmus which gives rise to haemorrhage 
must be treated bv the remedies found necessary after investio-atino; 
the cause. So, also, with diseases of the stomach, bowels, and liver, 
as well as with the effect of cold or of long-continued heat. 

Subinvolution and chronic congestion of the whole uterus require 
to be treated very much alike, by the application of such remedies as 
condense the uterine tissues, — ergot, belladonna, quinia, electricity, 
cold injections, compresses, and sitz-baths. When there is no tender- 



CURATIVE TREATMENT OF MENORRHAGIA. 143 

ness, ergot will be found a very efficient remedy, if administered for 
a sufficient length of time — several months, for instance. If there is 
considerable tenderness and pain, belladonna and quinia will be best 
adapted to the case. Ergot in some instances induces sensitiveness and 
heat in the pelvic organs, and then it should be used very cautiously. 
This effiect of ergot is especially noticeable when there is chronic local 
peritonitis or cellulitis. If there is a high degree of sensitiveness, a 
mercurial alterative may very properly be given in connection with 
the belladonna and quinia,^and a good form for administering it is the 
bichloride of mercury dissolved in the compound tincture of cinchona; 
or we may use mercurial inunction, or mercury in suppositories. I 
have not been able to do much good in these cases with iodine in any 
form. If given with iron, as the iodide of iron, it has occasionally 
a good tonic and alterative influence. These conditions of the uterus 
are very obstinate, and require a continuous treataient, oftentimes for 
many months. 

The treatment of endometritis, described elsewhere, consists mainly 
in a persev^ering continuance of stimulating applications to the dis- 
eased mucous membrane. I do not like the term caustic, for even 
the strongest remedies used for this purpose are applied so sparingly 
that their effects are little more than strongly stimulative. In the 
light of our present knowledge of the processes of menstruation, 



Fig 




The Dull Curette. 

these remedies, as suggested by Dr. Atthill, should be resorted to 
immediately after the monthly flow has ceased. By common consent 
of the profession, in this country, the treatment of granulations of 
the uterine mucous membrane consists in scraping them offi If the 
mouth of the uterus is sufficiently patent to admit a small-sized 
curette, the scraping may be done eflectually without dilatation; if 
not, a cupelo or sea-tangle tent may precede it. 

The curette should be passed over every point in the uterine cavity 
Avith firmness enough to detach the soft excrescences, and yet there 
should not be force enough employed to wound the natural tissue. 
Success will generally be announced by the discharge of the soft elon- 
gated growths. These are sometimes very abundant. The scraping 



144 MENORRHAGIA AND METRORRHAGIA. 

shoiilcl be done during the flow. It is not necessary to wait for a 
protracted paroxysm to pass by. 

Although not curative, tlie same treatment may be mentioned as 
most efficacious in arresting the haemorrhages resulting from cancer- 
ous granulations. In a discussion of Dr. Hanks's recent paper, Dr. 
Peaslee gives the very judicious advice not to cut into the sound 
tissue in the process. In cases of malignant fungus, we may often 
arrest the tendency to haemorrhage by injecting alcohol, by means of 
a hypodermic syringe, deeply into the substance of the part. This 
process frequently repeated sometimes retards the growth very mate- 
rially. The tincture of the chloride of iron, similarly used, will often 
have the same effect. 

The various conditions which give rise to retardation of the venous 
circulation require to be treated according to the improved methods 
now so well understood by the profession. The displacements of the 
uterus, which are arranged among these conditions, must be corrected 
by the various ingenious appliances designed for this purpose. And 
this may be done during the time of the preternatural flow with the 
expectation of moderating it at once. 

Dr. T. D. Fitch, of Chicago, has recently proven this last assertion 
in the management of a case occurring in a patient who had just 
passed the menopause. The uterus was retroverted, and all the means 
resorted to did not even moderate the metrorrhagia until the organ 
was elevated and retained in position by an appropriate pessary, when 
in a short time the bleeding ceased. After the subsidence of the flow, 
the patient removed the instrument, on account of some slight incon- 
venience which it gave her, but the flooding began again in a very 
few hours, and continued, notwithstanding repeated efforts to arrest 
it, until the pessary was once more introduced, when the haemorrhage 
again subsidal, and has not returned. The patient was still wearing 
the pessary when I heard of her case. 

The extreme danger from lisemorrhage connected with fibrous 
tumors of the uterus is not so often encountered since the profession 
has become acquainted with the great influence exerted upon certain 
conditions of the unimpregnated uterus by ergot. It is now under- 
stood that fully seventy-five per cent, of haemorrhagic cases of fibrous 
tumor of the uterus mav be rendered free from danger, as far as the 
haemorrhage is concerned, by an intelligent and persevering use of 
ergot, and that in twenty per cent, the tumors may be removed. In 
using ergot, in these cases, the mode of administering it cannot be 
uniform. Some patients cannot take it in any sufficient doses to 



TREATMENT OF MENORRHAGIA. 145 

answer the purpose; some cannot take it in the form of fluid extract, 
or wine, but can take the solid extract in the form of pills; others 
can take it in any form. When the stomach will not tolerate the 
er^ot, it may be given hypodermically, or per rectum in suppositories, 
and I believe that it can be made to act efficiently when given in any 
of these ways. 

Whatever method or form ^ve may adopt in the administration of 
ergot, we should give it in sufficient quantities to produce a sensible 
effect by causing contractions and pain, and there is no better rule to 
guide us, so far as I can judge, than to give it in increasing doses 
until that result follows. Twenty minims of the fluid extract, three 
times a day, will sometimes be sufficient, while some patients, on the 
other hand, will require twice or three times as much to produce the 
effect. 

The length of time required to obtain the ultimate effects of the 
ergot in these doses varies as much as the quantity required. The 
tumor will sometimes diminish very rapidly, but generally the de- 
crease in size is quite slow. From one month to over a year may be 
required to accomplish a cure when it can be accomplished at all. 
Ergot is sometimes very violent in its action, but by withdrawing it 
temporarily, lessening the dose, or combining and alternating it with 
anodynes, it may be safely managed. Although I have given it ex- 
tensively, and for a long time together, I have not seen anything 
worse than inconvenience arising from its use. 



10 



CHAPTEE VIII. 

DYSMENOEEHCEA. 

This is a general term for painful and difficult nienstruation, and 
includes conditions widely different in their nature. In some cases 
no appreciable morbid changes are discoverable in the organs which 
seem to be the seat of pain, either during or between the times of 
the menstrual flow, and these are called neuralgic dysmenorrhoea. 

They depend upon a general state of the system, which is sup- 
posed by some to be rheumatic and by others purely neuralgic. It 
would be difficult to define with any accuracy either of these condi- 
tions, the rheumatic or the neuralgic diathesis, and yet we know 
enough about their manifestations to be able to detect their presence. 

The character of the symptoms of this form of dysmenorrhoea is 
determined by the conditions of the system. 

It generally occurs in patients who are manifestly subjects of one 
of these diatheses, and who in the intervals between the periods ex- 
perience neuralgic symptoms, or symptoms referable to rheumatism. 

These features of the cases are sometimes so marked as to be easily 
detected, while at other times they are not well defined. Whether 
there is some permanent morbid condition of the nervous apparatus 
of the pelvic organs that is perpetuated from month to month, and 
thus constitutes the disease, or whether in neuralgic patients the vas- 
cular and nervous disturbance of the menstrual period is sufficient to 
excite and localize the morbific energ-ies of this diathesis, we do not 
know. I have been in the habit of teaching the latter. The par- 
oxysm of suffering is more irregular with reference to the com- 
mencement of the flow than in any other form of dysmenorrhoea. 
More frequently than otherwise the pain begins one, two, or even 
three days before the time of the flow, and continues in a subdued 
degree during a great part of the time of the flow. It is sharp 
and paroxysmal, but not generally accompanied with tenesmus. The 
pains do not seem to be influenced much by the flow. The intensity 
of the symptoms vary from slight and very tolerable pains in some 
patients to the greatest agony in others. 

This kind of dysmenorrhoea occurs in that class of patients of 



DIAGNOSIS — PROGNOSIS — TREATMENT. 147 

whom it is often said, ^' They suffer more than any one else from the 
same cause." They are very nervous patients. The seat of the pain 
is not always the same; sometimes it is referred to the uterus exclu- 
sively, but generally the pain radiates to the ovaries, the back, in the 
region of the genito-spinal centre, and down the limbs. 

Diagnosis. 

A physical examination of the pelvic organs enables us to declare 
that there is none of the morbid conditions we usually find in the 
other forms. This, with th^ diathetic manifestations, is the only means 
of arriving at definite conclusions. 

Prognosis. 

This affection, although it is obstinate and resists treatment of al- 
most every kind, and is apt to return after it was supposed to be 
cured, yet the effects of judicious treatment upon it are quite 
marked. 

Treatment. 

Change of climate, scenery, and modes of living are among the 
most promising remedies. I have known patients to be entirely free 
from dysmenorrhoeal paroxysms during a long tour in Europe, and 
others to be relieved by moving from a northern to a southern cli- 
mate. There is probably no better way to produce a decidedly salu- 
tary and lasting effect upon the nervous system of these patients than 
to revolutionize their surroundings by change of climate. A sum- 
mer residence by the seaside, the bathing and exercise connected with 
it will often suffice to interrupt, if not cure, the recurrence of these 
paroxysms. 

If we cannot remove the patient from the circumstances under 
which her disease originated, we may do a great deal to get rid of the 
diathesis by outdoor exercise on horseback, or on foot, and, if neither 
of these is possible, in a carriage. 

The diet should be reo^ulated with a view to an exalted state of nu- 
trition. Medicines may also be made to exercise a powerful influence 
upon the diathetic condition. 

In cases where we can trace a rheumatic taint we should give med- 
icines with a view to relieve it; among^ which are Dewees's tincture of 
guaiac. in drachm doses, three or four times a day, the tincture of ascle- 
pias tuberosa, or viburnum prunifolium. In the more purely neu- 
ralgic cases, tonics containing iron, strychnia, quinine, and 2)hosphorus 



148 DYSMENORRHCEA. 

are serviceable. The phosphide of zinc or the oxide of zinc will also 
be found very useful remedies for this general condition. 

The manner of treatment of the paroxysm is also of great impor- 
tance. As we can calculate with some definiteness the time when the 
paroxysm will come, we may anticipate it with such remedies as will 
produce a strong impression on the nervous system. 

The late Dr. M. B. Wright taught his students that large doses of 
quinine given one or two days before the expected paroxysm, with a 
view to having the patient pass into it in a state of cinchonism, often 
mitigated her sufferings very greatly, and sometimes entirely prevented 
it. If, as he supposed, many cases were due to malarial influences 
we might expect great good from this treatment. Arsenic is another 
remedy that will sometimes mitigate the suffering if given so as to 
exert its full influence at the time of the paroxysm. To do this its 
administration must be commenced at least a week before the return, 
and continued from small to increasing doses until characteristic 
effects appear. In giving remedies for the relief of pain during the 
paroxysms we should have in mind that patients afflicted with this 
form of dysmenorrhoea are easily fascinated with the effects of ano- 
dynes and give them up with great reluctance, and that there is there- 
fore great danger of making opium-eaters of them. 

I could point out a number of patients who have abused the pre- 
scriptions given them for this purpose to their great sorrow. 

We should feel a proper sense of responsibility in these cases, use 
anodynes as sparingly as possible, and place them beyond the reach 
of the patient when the urgency of the symptoms has passed. Chloral, 
chloroform, and morphia are the anodynes upon which we will be 
obliged to rely in the extreme agony of a paroxysm. 

The Inflammatory Form of Dysmenorrhoea. 

In this variety of dysmenorrhoea the condition giving rise to the 
paroxysm is inflammation in some of the pelvic organs, generally the 
uterus, the ovaries, or both. Whether there is a pure ovarian dys- 
menorrhoea of this nature or not, I am not prepared to positively 
assert, but I think it very probable that there is. In most cases of 
inflammatory dysmenorrhoea, however, I believe the morbid condition 
exists in both the ovaries and uterus. In exceptional instances the 
inflammation may be located in the cellular tissue, and perhaps in 
other pelvic structures. 



THE INFLAMMATORY FORM OF D YSMENORRUCE A . 119 

Si/mjjtoms. 

Patients laboring under this form of the affection are generally the 
subjects of intramenstrual syniptonis of sufficient intensity to mark 
the nature of the causing conditions. They are the usual symptoms 
of uterine or ovarian disease. It is in this form that intramenstrual 
paroxysms occur midway between the menstrual periods. These intra- 
menstrual paroxysms are sometimes very severe, but probably are not 
so intense as those occurring during the periods. 

The paroxysms usually commence some hours, and, occasionally, 
a day or two before the flow, and partially or completely cease as 
soon as the flow is established and becomes free. The pain is gen- 
erally of a somewhat steady aching character, not so intense, but 
more continuous than the neuralgic form. The paroxysm is usually 
attended with febrile phenomena. Sometimes there is a sharp attack 
of fever, preceded by chilliness, and accompanied with furred tongue, 
headache, and pain in the limbs. The pain is not always confined to 
the pelvis, but radiates upward and downward. The paroxysm is 
usually accounted for by supposing that the pain due to the existing 
inflammation is very much aggravated by the hypersemia and hyper- 
esthesia attendant upon the occurrence of menstruation. However 
this may be, they are distinguished by this similarity to the pains of 
inflammation. 

Diagnosis. 

A thorough physical examination, for which I will refer the reader 
to the diagnosis of uterine disease, will enable us to discover the lo- 
cality, character, and grade of the morbid process. 

Prognosis. 

The prognosis of this form of dysmenorrhoea I believe to be more 
favorable than any of the others, because more amenable to treat- 
ment. It does not cause that intensity of suffering which we witness 
in some of the other varieties. 

It may not be irrelevant to state here that while we do meet with 
pure examples of neuralgic and inflammatory dysmenorrhoea tliere is 
often an obvious neuralgic element in the inflammatory form — a 
complication of the two varieties. Sometimes one of these morbid 
conditions predominates, and sometimes the other. 

Treatment. 

For the special treatment of the inflammation as the controlling 
element in this afiection I must refer the reader to the methods of 



150 DYSMENORRHCEA. 

treatment elsewhere given. The progress of the cure of that element 
will be marked by the subsidence of the intensity of the paroxysms 
until they fail to return. 

In this form we may often anticipate the paroxysms, and allay 
them by appropriate treatment. The patient should be directed to 
take her bed before it comes on, and remain quiet until the paroxysm 
is over. Particular attention should be directed to her bowels, and 
it will often be best to give her a small mercurial — two or three 
grains of calomel, and follow it in seven or eight hours by a saline 
cathartic. After this diaphoresis should be encouraged by the ace- 
tate of potash, and, as the pains begin, Dover's powder. The antici- 
patory local treatment consists in bloodletting by leeches or scarifi- 
cation the day before the expected paroxysm. Hot-water injections, 
continued through the attack as often as three or four times in twenty- 
four hours, hot fomentations over the hypogastrium, and tepid sitz- 
baths. These will often do away with the necessity of using ano- 
dynes. When the pain is not relieved by these measures anodynes 
in sufficient quantities to mitigate it are permissible. 

Membranous Dysmenorrlioea. 

The particular feature of this form of dysmenorrhoca is the dis- 
charge of a membranous cast of the cavity of the uterus. Some- 
times the membrane comes away without losing its shape or integrity ; 
very much more frequently it is discharged in a broken condition, 
and appears in shreds or large pieces, representing in shape and size 
the anterior or posterior wall of the cavity of the uterus. 

" The microscope shows that the discharges at times consist simply 
of fibrinous clots, which are with difficulty passed through the os 
uteri, when it is very small, as is frequently the case in females who 
have never borne children ; at other times the fibrin is in a fibrillated 
state, inclosing in its reticulum numerous lymph and epithelial cells. 
In other cases there are found irregular shreds, containing capillary 
vessels with embryonic walls, in the midst of connective tissue, infil- 
trated with lymph-cells. There are also frequently seen fragments 
of uterine glands. This is a genuine discharge of exfoliated mucous 
membrane. The mucous membrane maybe expelled entire; this, 
however, is not of frequent occurrence."* 

Numerous theories have been proi)agated to explain the formation 

* Cornil and Kanvier's Pathological Histology, translated by Shakespeare and 
Simes, p. 685. 



MEMBRANOUS DYSMENORRHCE A. 151 

of this membrane. It would seem that the ideas prevailing with 
reference to the formation of the deciduous membrane have influenced 
the profession in their opinions as to the conditions giving rise to this 
membranous formation. 

In the theory adopted by Dewees, Montgomery, and others, that 
it was a layer of plastic lymph spread upon the uterine wall, we see 
something of the Hunterian explanation of the formation of the de- 
cidua. In another theory, adv^anced by Oldham and others, we see 
the results of the researches of Coste, who considers the decidua 
nothing more than the mucous membrane of the uterus, changed by 
impregnation. According to this theory it is the menstrual decidua 
which does not undergo disintegration as completely as in health; 
in other words the membrane is the result of hyperuidation. In 
the natural condition of the uterus the mucous membrane under2:oes 
changes that render it suitable to become the nidus for and to em- 
brace and fix the ovum in its development. When conception does 
not take place the disintegration of the membrane and the flow are 
contemporaneous. If the membrane is overdeveloped by reason of 
a preternatural amount of connective tissue, then the membrane re- 
tains its integrity to a certain degree, and instead of flowing out as 
debris it is expelled as a whole or in large shreds. 

I believe with Scanzoni that the uterus in which the formation of 
this membrane occurs is in a state of hypersemia. Sometimes this 
hypersemia is trophic, and then the membrane will contain capillary 
bloodvessels and utricular glands, while in others it is inflammatory, 
and the discharge will contain fibrinous clots and false or fibrinous 
membrane, inclosing in its reticulum lymph and epithelial cells. 

This view of the subject will enable us to explain the microscopic 
appearances noticed in different cases. Clinical observation will also 
sustain the position that inflammation is the main factor in a portion 
of these cases at least. 

In the cases in which there is trophic hyperemia, the initial or 
actuating condition is probably nervous, and the influence reflected 
through the ovaries, as in the production of normal menstrual con- 
gestion or the hypersemia of pregnancy. 

Symptoms. 

The paroxysm is sometimes ushered in by nausea, vomiting, rapid 
pulse, furred tongue, headache, and increased temperature, and in 
many respects resembles inflammatory dysmenorrhoea ; at other times 



152 DYSMENORRHCEA. 

there are no febrile symptoms; but in most cases of membranous 
dysmenorrhoea the stomach sympathizes with the pelvic trouble. 

The pains usually begin after the commencement of the flow and 
continue until the membrane passes. They are at first sharp, and 
dart from the pelvis in every direction, afterward cramping, and 
finally tenesmic or expulsive. The pains have for their object the 
separation and expulsion of the membrane, and subside as soon as 
this is accomplished. 

The more complete the formation of the membrane, the more 
urgent and painful the efforts to get rid of it. The most distressing 
part of the suffering depends upon the effort to overcome the resist- 
ance of the OS uteri to the evacuation of the membrane. 

Without this resistance it is uncertain whether there would be 
much pain, as I have known two cases in which the membrane was 
repeatedly evacuated without pain. In both cases the internal os 
uteri was patulous. I have never seen the membrane expelled by 
parous women. 

Diagnosis. 

This depends upon the discovery of the membrane either in pieces 
or as a whole. While my observation has not been sufficiently ex- 
tensive to enable me to establish a rule even for my own guidance, I 
believe it will be found that in cases attended with febrile symptoms 
the membrane will be of a plasmic character wholly, and that in 
those unattended by these symptoms the membrane will partake more 
of the deciduous character. 

The prognosis of membranous dysmenorrhoea is not very encour- 
aging, as it is very difficult to overcome the disposition to the forma- 
tion of the membrane. 

Treatment. 

The paroxysm of membranous dysmenorrhoea, especially the more 
febrile form, should be treated with a view to removing the obstruction. 
The cervix should be dilated by Hunter^s or some other dilator as 
soon as the pains become severe and ex[)ulsive in character; this will 
generally very materially shorten the duration, as it facilitates the 
discharge of the membrane. In connection with the dilatation, or 
without, an efficient dose of ergot will sometimes aid the process of 
expulsion very materially. 

Sometimes we may prevent or mitigate the severity of a paroxysm 
by using a fasciculus of slippery elm tents a day or two before it 
occurs, especially in the febrile form. 



OBSTRUCTIVE DYSMENORRnOE A. Ic3 

If the paroxysm is attended with vomiting and fever, we should 
anticipate it by giving a cathartic the day before its occurrence and 
administer large doses of quinine. 

The administration of ergot between the paroxysms in the trophic 
variety will aid very materially in overcoming the hypersemic con- 
dition of the uterus, and produce a favorable influence upon the 
nerve-centres that preside over the process of ovulation. Mercurial 
and iodine alteratives should take its place in the inflammatory va- 
riety. The ammoniated tincture of guaiac. may be given with great 
propriety when a rheumatic diathesis is suspected. The local treat- 
ment of the two is very nearly the same, viz., dilatation and appli- 
cations to the mucous membrane of the cavity of the body of the 
uterus, as in cases of chronic inflammation and congestion of that 
organ. 

Obstructive Dysmenorrhcea. 

The clinical study of dysmenorrhcea will force upon the observer 
the conviction that, in the majority of cases, this symptom is the 
result of uterine contractions, and that the contractions are efforts 
made by the uterus to expel its contents. 

As I have already shown, this is the case in the membranous va- 
riety, the real cause of the expulsive pains being obstruction, not 
because there is contraction of the os uteri or cervical canal, but be- 
cause the substance expelled required more room for its passage than 
was affordeed by the os of normal size. 

In the inflammatory variety the same kind of pains are often no- 
ticed. Doubtless the cause of the expulsive efforts in this variety is 
the temporary stenosis of the internal os uteri, caused by the tume- 
faction of the mucous membrane at tl at point at the time of the 
menstrual congestion. This explanation presupposes endometritis 
with the greatest intensity of the inflammation at that point. Be- 
tween the menstrual periods the tumefaction subsides, and the os 
presents no evidence of stenosis. This is one form of temporary 
stenosis causing dysmenorrhcea. Another is spasm of the circular 
fibres surrounding the internal os uteri at the time of menstruation. 

We are prepared to understand how this may take place in patients 
of irritable fibre, when we remember the hypereesthesia that accom- 
panies chronic inflammation of the uterus and the congestion preced- 
ing the eruption of the menstrual discharge. 

1 have no doubt that the cause of temporary stenosis, even in the 
inflammatory form, is often spasmodic closure, as blepharospasm is 
caused by conjunctival inflammation. 



154 DYSMENORRHCEA. 

I think this spasmodic action is much more likely to occur in the 
inflammatory than in the neuralgic variety. There is one condition 
in which the expulsive pains of dysmenorrhoea manifest themselves 
with great severity where no stenosis exists. When there is a great 
degree of retroversion or retroflexion the cavity of the body is lower 
than the Internal os uteri. 

In such cases the extravasated blood, instead of flowing toward the 
mouth of the uterus, gravitates into the fundal portion of the cavity 
and there accumulates until its presence excites uterine contractions. 

It would seem from these considerations that much of the suffer- 
ing connected with retroflexion, and even anteflexion, with or with- 
out stenosis, is fairly attributable to the gravitation of the blood into 
instead of out of the uterus. 

I w^ould call attention to the figure of retroflexion, here introduced, 
to demonstrate this proposition : Would it be possible, even if there 

Fig. 39. 




Strong Retroflexion favoring Gravitation to the Fundus. 

was no stenosis, for the blood to flow out of a uterus in the position 
there represented? And would not the accumulation of the blood 
in the dependent cavity, and perhaps coagulating there, as certainly 
produce eflbrts at expulsion as any other foreign body? Since my 
attention has been directed, especially to this item, in the pathology 
of dysmenorrhoea, I have been convinced that too much importance 
has been attached to simple stenosis. 

Nearly all cases of obstructive dysmenorrhoea are associated with 
displacement or flexional deformity of the uterus. When gravity 
favors the outflow of the menstrual blood it requires only a very 
small passage through which to escape. I have repeatedly examined 
patients, in whom the external os uteri was not larger than a pin- 



OBSTRUCTIVE DYSMENORRHCE A. 155 

hole, whose menstrual flow was easy and copious. AVliile thus ex- 
pressing myself with reference to the importance of malposition and 
flexion.d deformity of the uterus as offering a sufficient impediment 
to the discharge of the blood to induce the most distressing form of 
dysmenorrhoea, I would not ignore stenosis as one of the causes of it. 
Any cause that will give rise to retention of the menstrual flow 
will cause uterine contractions and pain. A typical case, in which 
dysmenorrhceal symptoms from forcible retention of the menstrual 
fluid are manifested, is congenital occlusion of some portion of the 
genital canal. If the obstruction is at the orifice of the vagina, the 
pains will not be of this character until the vagina is filled an(> a 
portion of the blood is retained in the uterus; but if the occlusion 
is at the uterus, the symptoms will begiu with the first menstrual 
effort. To witness a case of this kind will convince the observer 
that obstruction to the flow will give rise to dysmenorrhceal symp- 
toms. If there is a great degree of stenosis in a part of the genital 
canal symptoms of a similar character will occur. 

Symptoms, 

The main symptom of obstructive or retentive dysmenorrhoea is 
excruciating pain of an expulsive character. The pains are compared 
to colic, and the term uterine colic is c^uite appropriate. 

They generally come on before the commencement of the flow, and 
continue until the discharge is well established, when they gradually 
subside, and the flow continues from that time on without pain. In 
many instances the great congestion accompanying the effort at dis- 
charge, causing a sort of erection of the uterus, not only overcomes 
the stenosis, but it temporarily, to a great extent, corrects the position 
or deformity; without this correction the relief would not be com- 
plete. If the attendant will take the trouble to examine patients 
carefully during the flow — which by the way is very seldom done — 
he can easily convince himself of the truth of this statement. 

Diagnosis. 

The diagnosis may be established by physical examination. Ob- 
struction of the vaginal orifice by the hymen, morbid adhesions, or 
congenital deformity may be detected by ocular, digital, and instru- 
mental examination with the sound during the presence of the symp- 
toms. Malposition or flexions will be detected by physical examina- 
tion. 



156 DYSMENORRHCEA. 

Prognosis, 
Like the other forms of dysnienorrhoei, the obstructive variety is 
apt to be very obstinate and difficalt to manage satisfactorily ; but 
as the corrective treatment is almost wholly mechanical or surgical, 
we may hope for good results. 

Treatment 

In cases where there is retroflexion with dependent fundus, the first 
and most important corrective measure is to elevate the organ so that 
the blood will flow into the cervix, and thus escape from the os uteri. 

This may be done before or at the time of the paroxysm. If we 
see the patient for the first time during a paroxysm, we should place 
her in the knee-chest position, and lift the fundus uteri up with one 

Fig. 40. 




Retroflexed Uterus with the Fundtls raised by a Pessary, 

finger. By this means we straighten out the cervix, and thus dilate 
the contractions and give the blood an inclined plane over which to 
flow and escape. 

This I am assured from repeated observation will often relieve a 
paroxysm. If this is not sufficient, with the patient still in the genu- 
pectoral position, we should introduce a sound to the fundus. In 
some cases elevating the womb, with or without the introduction of 
the sound, will relieve the patient for a few hours only; but if the 
pain returns, it may be relieved in the same way until the paroxysm 
subsides. Between the paroxysms a suitable retroversion pessary 
should be worn, and, if properly placed and watched, will go a great 
way toward effecting a cure. 



Rf» 



OBSTRUCTIVE DYSMENORRHCEA. 157 

AVheii there is stenosis, we may often relieve the paroxysm by 
dilating the contracted point with a slippery-elm tent. 

There are two principal methods of relieving stenosis, viz. : 1st. 
By incision. 2d. By dilatation or stretching the parts, by instru- 
ments made for the purpose, and tents. 

Dr. Sims in his work on Uterine Surgery propounds the following 
opinions as to the causes of dysmenorrhooa, and bases his treatment 
on them. lie says (page 142): 

*' It (dys'raenorrhoea) is only a symptom of disease, which may be 
caused by inflammation of the cervical mucous membrane, retroflexion, 
anteflexion, flbroid tumor in one wall of the uterus or the other, con- 
traction of the OS externum, flexures of the canal of the cervix, either 
acute or greatly curved, either at the os internum, at the insertion of the 
vagina, or extending throughout the whole length of the canal, all of 
which are but so many mechanical causes of obstruction which must be 
recognized and remedied if we expect to cure the dysmenorrhoea." 



The following table is on page 132 : 

f OS was normal in but 
OS was contracted in 
Of 100 cases of painful menstruation, ....-{ cervix was flexed in 

congested in . . . 

[there were polypi in 

f OS was normal in 

OS was contracted in 

Of 29 cases of excessively painful menstruation, \ cervix was flexed in 



had polypi in 
[was congested in 



6 

90 

61 

7 

2 



26 

23 

2 

1 



This tabular testimony of 129 cases is a strong argument in favor 
of Dr. Sims's theory, that dysmenorrhoea is almost always caused by 
obstruction. 

As I have given the opinion of Dr. Sims as to the causes of dys- 
menorrhoea, I cannot complete this article without giving the reader 
an idea of the mode of treatment found most successful by him, viz., 
that of dilating and strengthening the canal of the cervix. He ex- 
poses the mouth of the uterus by placing the patient in the same 
position, and using the same instrument as for vesico-vaginal fistula. 
AVith a tenaculum he seizes and firmly holds the cervix, and draws 
it into the most convenient position. If the cervix is not flexed but 
merely narrow, he introduces one blade of the scissors into the canal 



158 



DYSMENORRHCEA, 



of the cervix far enough to divide it on one side up to the junction 
with the vagina, and then closes them. The other side of the cervix 

Fig. 41. 




rig. 41 represents the operation for dividing tlie straiglit cervix when too narrow. The dark 
part is the portion cut. On one side the knife is shown in the act of dividing the tissues. 
This is Dr. Sims's plan. 

is divided to the same extent in like manner, then, by means of the 

knife represented in figure, he divides the cervix up as high as the 

internal os. 

Fig. 42. 




Emmet's Knife for dividing the Cervix. From a cut in the June Number, 1864, Xeiv York 
Journal of Medicine. 

If the cervix is flexed, the lip of the uterus on the convex side is 
divided to the same height, and then the cervix opened with the 
knife. In this way the cervical canal is rendered rectilinear. 



RMt 



PEASLEE S METHOD. 



159 



This is represented by Fig. 43, taken from page 169 of Dr. Sims's 
work on Uterine Surgery. It shows the posterior lip already divided 
by the scissors, the tenaculum fastened into the anterior lip, and the 
knife being inserted as high as necessary. 

Fig. 43. 




" The representation in the cut is taken from the perfected instrument 
made by Wade & Ford, of New York city. To their ingenuity is due 
the application of the principle. The representation is half the size of 
the instrument, but the blade at full size is out of proportion, as it should 
be represented both longer and narrower." 

After Laving thus completed the operation Dr. Sims places in the 
wound of the lip of the cervix some cotton saturated with glycerin, 
and then proceeds to fill the vagina with cotton to guard against 
h^emorrhao^e, which he reo;ards as alwavs imminent. If there be but 
slight bleeding, it is not necessary to use more cotton than will keep 
the dressing in place. The patient should keep the recumbent pos- 
ture for several days. The cotton in the vagina may be removed in 
twenty-four hours after the operation ; that in the wound remains 
from two to three days. Dr. Emmet recommends that the sound be 
passed through the cervix every other day until the discharge ceases 
to prevent the parts from adhering. The sound need not be used 
for this purpose until the tampon is dispensed with. 

The following are the conclusions in practice of the late Dr. E. R. 
Peaslee :* 

" From the preceding facts I deduce the following conclusions : 
" I. The deep incision of the cervix throughout, and complete bilateral 
discission of the vaginal portion with deep incision above, are alike fre- 

* A paper read before the Kew York Academy of Medicine, 1876. 



160 DYSMENORRHCEA. 

quentl J attended by certain immediate dangers, and not seldom produc- 
tive of certain serious remote consequences, viz., profuse and sometimes 
fatal haemorrhage, pelvic cellulitis, septic peritonitis (usually fatal), 
sterility, if not previously existing, and a tendency to miscarriage. 

"II. Those risks and effects are all due to the extensive division of 
the walls of the cervix, and to the consequent enlargement of the cer- 
vical canal ; and the sole compensation for all of them which can be 
calculated upon is the relief, and very often the cure, of stenotic dys- 
menorrhoea. 

"It therefore becomes a question of very great practical importance 
whether the amount of cutting may not be so far diminished as to avoid 
all these risks, and at the same time be sufficient for the cure of stenotic 
sterility and dysmeuorrhcea. But another inquiry antecedent to this is, 
how large a calibre of the cervical canal is actually required for the re- 
lief of these two conditions ; and a reply sufficiently definite for all prac- 
tical purposes is not so difficult as might appear. 

"In the imparous woman, the narrowest point of the cervical canal, 
viz., the internal os, is, when opened by the passage of the menstrual 
fluid, an ellipse, whose conjugate and transverse diameters average re- 
spectively one sixth and one-eighth of an inch ; its area corresponding 
very nearly* with that of a circle one-seventh of an inch in diameter. 
The external os, also elliptical when moderately dilated, has diameters 
averaging one-fourth and one-sixth of an inch. It thus has an area ex- 
actly twice that of the internal os, and equalling that of a circle one- 
fifth inch in diameter.f The larger size of the external os doubtless 
has a special reference to conception, and favors the entrance of the 
spermatic fluid into the cervical canal. It has no special influence 
against dysmenorrhoea, since the menstrual fluid, after having passed 
through the internal os into the cervical canal, would pass just as easily 
from the latter through an opening of the same dimensions into the 
vagina. Hence, we not very seldom see imparous women with the ex- 
ternal OS no larger than a ' pin-hole,' and who, nevertheless, do not 
suffer from dysmenorrhoea, though, as a rule, they are sterile. But if 
the lining membrane of the canal becomes thicker from congestion, or 
some other cause, such patients suffer at once from stenosis at the ex- 
ternal OS. 

" In the parous woman, the size of the external os varies within quite 
extensive limits, since it is exposed to so many of the accidents of par- 
turition, while the internal os is more nearly uniform. 

" I have deemed it desirable to ascertain the lowest average diameter 
of the two ora uteri in parous women, who are neither sterile nor have 
dysmenorrhoea, as a rational standard for determining the extent of in- 

* Tlie circle i« smaller than the ellipse, in the proportion of 144 to 147. 
f Circle to ellipse as 72 to 75. 



■B 



peaslee's method. 161 

cision actually required for the removal of these two conditions when 
stenotic. And, after a good deal of observation in this direction, I find 
that the inner os presents nearly twice the area of that of the imparous 
woman ; in the majority of cases admitting a sound one-fifth of an inch 
in diameter, though, in a large minority, one from one-fifth to one-sixth 
of an inch only can be easily passed. I therefore regard a diameter of 
one-fifth of an inch as ample for the removal of sterility and dysmen- 
orrhoea. I find the external os admits a dilator one-fifth of an inch in 
diameter and upward — in some cases as high as one-fourth or even three- 
tenths of an inch — but, as a rule, I think one-fourth of an inch sufficient 
for the purpose. It is of course to be understood that no narrowing of 
the canal exists between the two ora. Since, however, there may be 
some deo^ree of stenosis for the menstrual fluid, while not for the sound, 
it is sometimes judicious (and especially if congestion of the cervical 
lining membrane coexists) to increase the dimensions just named, by the 
use of a dilator of the next larger size. I do not assert that the pre- 
ceding dimensions are always required in the treatment of stenotic ster- 
ility and dysmenorrhoea, for they are not, nor that they are never to be 
exceeded, but that in almost all cases they will be found sufficient. 

"Should this precise specification of dimensions seem too minute for 
practical purposes, we must remember that dimension cannot here have 
a less important relation to function than elsewhere; and that enlarging 
the internal os to the diameter of half an inch, as is often done by the 
deep incision, is, as has been seen, like permanently dilating the urethra 
(if it could be done) to the size of the small intestine. And the impor- 
tance of making an incision of the internal os, with a precise intention 
and a precise knowledge of the mode of accomplishing what is intended, 
may be understood when I state that if the circle representing its area 
in the imparous woman be increased equivalently to surrounding it by 
a ring only one thirty-fifth of an inch wide, its area is increased as forty- 
nine to twenty-five, or almost exactly doubled. Or if an incision be 
made on each side of it to the extent of half a line (one twenty-fourth 
of an inch), and it then be dilated to a circle, it is increased two and a 
half times. And if the cut should extend one line to the right and the 
left, or the added ring were one-twelfth of an inch wide, the area would 
be increased more than four times and a half. This last increase is far 
more, in my experience, than is ever required in stenotic sterility and 
dysmenorrhoea. 

Superficial Trachelotomy — My oivn Operation. 

" III. Desiring to restrict the operation of trachelotomy in the treat- 
ment of stenotic sterility and dysmenorrhoea within the limits actually 
required, I, some ten years ago, devised and brought before the New 

11 



162 DYSMENORRHCEA. 

York Obstetrical Society* a series of five steel cervical dilators, to be 
used instead of incision, where the stenosis is slight and the cervix is 
normally soft and pliable. These, in shape and size, have a precise 
reference to the dimensions of the cervical canal, and especially of the 
two ora uteri, as already specified ; and each is guarded by a bulb, so as 
to project through the internal os into the uterine cavity only about one- 
quarter of an inch. 

" But finding that almost all cases of stenosis of the cervical canal are 
relieved more promptly, more permanently, and also with less pain, by 
incision, or this together with dilatation, than by any form of dilatation 
alone, I next endeavored to restrict the extent of the incision within the 
absolutely necessary limits, having determined them approximately by 
the preceding facts and calculations. To this end I devised a new 
method, and an instrument for executing it, which I also laid before the 
New York Obstetrical Society about eight years since ; but the former 
was so simple, bloodless, and unpretending, in comparison with the pro- 
cedures of Simpson and Sims, that it excited but little interest. Mean- 
while, however, it has been sufi&ciently tested, I think, by myself and 
my pupils in diflferent parts of the country, to entitle it to a more general 
notice. 

"Since the superficial incision, as suggested by myself, has for its 
direct object merely the removal of stenosis of the cervical canal, and 
is therefore proposed for the treatment of stenotic dysmenorrhoea and 
sterility only, it is previously to be decided whether stenosis actually 
exists. And the following propositions will aid in settling this question, 
it being understood that the exploration is to be made at least four days 
after, and at least three days before, the catamenial flow. 

A. Respecting Stenosis of the Internal Os. 

"1. If a sound one-fifth of an inch in diameter passes easily through 
the cervical canal, there is no stenosis at the internal os, and no incision 
is there required. This is the size, therefore, of my large sound. 

" 2. If a sound one-sixth of an inch in diameter be easily j^assed, as 
above, there is no absolute, though there may be relative stenosis of the 
internal os; i. e., there may be stenosis for the passage of a fluid, though 
not of the sound; and an incision to make it one-fifth of an inch may be 
required, but not unless the symptoms indicate it. 

"3. If the sound easily passed be but one-seventh of an inch in diam- 
eter, and there are no symptoms of stenosis, no incision of the internal 
OS is required. This is the normal size in the imparous woman, and the 
average size of Simpson's sound. 

"4. If a sound but one-eighth of an inch in diameter cannot be passed 

* Also described in the New York Medical Journal, July, 1870, p. 478. 



peaslee's method. 163 

tbrougli the intei'Dal- os, there is either stenosis or, what is very much 
more probable, one of the flexions. Prove, therefore, that there is no 
flexion in this and every case in which a sound of any size does not 
traverse the internal os before operating for stenosis. I consider an in- 
ternal OS of one-eighth of an inch or less to be stenotic. Chrobak's high- 
est limit for stenosis of the internal os is one-tenth of an inch (two and 
a half millimeters). 

B. Respecting Stenosis of the External Os. 

'" 5. On the other hand, there is no stenosis of the external os if a sound 
one-fifth of an inch in diameter easily traverses it. If there be conges- 
tion of the lining membrane, however, there may be stenosis, practically, 
in respect to conception ; and the operation somewhat enlarging it (to 
one-quarter of an inch or more) may be required. 

"6. If the external os will not easily admit a sound one-sixth of an 
inch in diameter, there is probably stenosis in respect to conception, and 
the operation is required. If not more than one-seventh of an inch, 
the operation w411 also probably be required for dysmenorrhoea. 

" 7. In case of operation, the whole cervical canal must be made still 
to retain the normal fusiform shape as far as possible. 

"I. My metJiod consists in incising the internal os, if the stenosis exist 
at that part, — and the external, if at the latter, — to such an extent as 
to give to each its precise average dimensions in the parous woman, 
neither more nor less, and, of course, also overcoming any other point of 
stenosis existing anywhere else in the cervical canal. In cases compli- 
cated with congestion, however, I have shown that a slightly larger 
opening may be required, and, therefore, that the limits may extend be- 
yond one-fifth of an inch to nearly a quarter of an inch in the case of 
the internal os, and to three-tenths of an inch, and possibly more, of the 
external. 

"I do not, therefore, incise the internal or the external os to a given 
depth in all cases, but, taking them as I find them, cut just enough to 
give them their average normal size in the parous uterus. This is sel- 
dom one-half of a line and often not more than one-third of a line for the 
internal os, and not more than a line for the external. But, of course, 
there is far more variation in the latter. If the internal os admits a 
sound of but one-eighth of an inch in diameter, a cut on each side of 
nearly half a line (but three-eightieths of an inch) is required; and if 
but one-tenth of an inch in diameter, it must be one-twentieth of an inch 
deep on each side. The incisions are of precisely the same depth on 
each of the two sides. 

"Since the lining membrane at the internal os is at most one twenty- 
fifth of an inch thick, it is seen that I generally do not cut nearly 
through it. Indeed, when the os is but one-eighth of an inch wide, I 



164 



DYSMENORRHCEA. 



cut almost through the membrane; and when one-tenth of an inch, I 
divide it and one-hundredth of an inch of the tissue beneath it."^ 

"II. The instrument devised to secure this effect consists of a flattened 
tube, containing a blade. The former is eight inches long and seven- 
sixteenths of an inch wide, except its terminal one inch and three-quarters, 
which has a width of but one-eighth of an inch, as shown in Fig. 44. This 
portion is made curved by some instrument-makers, which is not an im- 
provement. The blade is of such a width as to slide accurately within the 
tube, having a nut and a screw attached to its proximal extremity to gauge 
the extent of its passage into the cervical canal, and a blunt point and lat- 
eral cutting edges for an inch and five-eighths at the distal end. There are 
two blades for each instrument, the cutting portion of one being a quarter 

Fig. 44. 




Dr. Peaslee's Metrotome, half size. 



of an inch wide, and of the other three-sixteenths of an inch. If the steno- 
sis is confined to the internal os, the narrower blade alone is used. If both 
ora are contracted, the wider instrument is passed through the external os, 
and the other blade then introduced and the inner os incised by it ; and in 
cases of decided congestion, the wider blade alone is sometimes used for 
both ora. In this case, a sound one-fifth of an inch in diameter is easily 
passed through the inner os; while, if the smaller blade had been used, 
considerable force would be required to carry it through. 

"In hospital practice I place the patient upon the side, use the duck- 
bill speculum, hold the cervix by means of a uterine tenaculum, pass 
the tube into the canal up to the shoulder, and, therefore, one-quarter 
of an inch into the uterine cavity through the internal os, when the 
blade, previously gauged, is introduced into the tube and carried up the 
cervical canal as far as is required to overcome the stenosis. My large 
sound (No, 10, American scale), or, still better, the conical dilator of 
the proper size, is then passed up the canal, and the operation is com- 
pleted. In private practice I generally place the patient on the back, 
and pass the tube into the cervical canal precisely as I would Simpson's 
sound, and then pass the blade through it, as just described. 

" If the external os is too narrow for the admission of the extremity 
of ray instrument, it may be enlarged by the introduction — generally 
one-eighth to one-quarter of an inch is far enough — of a narrow-pointed 

* The details of all the preceding calculations are properly omitted here, as a 
slight acquaintance with mathematics will enable the reader to verify them. 



peaslee's method. 165 

bistoury. I have not found the internal os too narrow to receive it, 
except in cases of flexion, or previous traumatic injury of the cervix. 

" The changes in the whole uterine cavity from this operation are 
shown by Fig. 46. Respecting its dangers I have but little to communi- 
cate. The hi^morrhage following it seldom exceeds one or two drachms, 
and never requires any special attention. The pain is very slight and 
momentary, and no anaesthetic is ever required. The medullary struc- 
ture of the cervix never being cut into, pelvic cellulitis and peritonitis 
do not ensue. The only exceptions to this statement in nearly three 
hundred cases are: one case in private practice, in which some febrile 
reaction and uterine tenderness ensued, which subsided entirely, without 
cellulitis, in four days; and two cases, in the Woman's Hospital, of 
slight cellulitis. But both the latter were patients who were known to 
have had cellulitis a short time previously, and I was obliged, by some 
peculiar circumstances, to operate sooner than I otherwise would have 
done. The final results were precisely as desired in each of these three 
cases. Otherwise I have never had any unpleasant symptoms follow the 
operation ; and the only precautions taken are to keep the patient two 
days, and sometimes three days, in bed, and not allow her to walk out 
under a week. I use the dilator every second day after the operation 
for a week, and two or three times more once a week. I have very often 
performed the operation at my office on residents of the city, and sent 
the patient home to bed after half an hour's rest, and have never had 
to regret it. I decline to operate within four days after or six days be- 
fore the catamenial period. 

"I claim for the method just described the following recommendations 
in the treatment of stenotic sterility and dysmenorrhoea : 

" I. It aims to restore the normal dimensions as existing in the parous 
woman throughout the cervical canal, nothing more and nothing less, 
unless where a slight exaggeration of size is required on account of co- 
existing congestion. 

*^ II. It effects this object definitely and with certainty, and with inci- 
sions exactly symmetrical, or equal on the two sides. 

"III. It gives no danger from haemorrhage, since the arteries nearest 
the internal os, if that is to be divided, are never reached, and the whole 
thickness of the lining membrane even is generally not divided ; and 
there are no arteries within the portion divided at the external os. 

" IV. There is no danger of pelvic cellulitis, except in those patients 
in whom the least operative interference with the cervix, or the use of 
the sound or of a sponge-tent, will produce it. I consider the opera- 
tion less dangerous in this respect than the last mentioned. 

" V. There is no danger of septic peritonitis, since the medullary sub- 
stance is not reached'by the incision. 

" VI. It does not produce sterility or tendency to abortion by mutila- 



166 



DYSMENORRHGEA. 



ting the cervical canal. The changes it produces in the latter, as com- 
pared with those from the operations of Simpson and Sims, are shown by 

Fiss. 45, 46. 47. and 48. 



r:c.. 





Xonnal I terine Cavitr. 



Ditto, as modined by Peaslee's Method. 



Fig. 47. 



Fi.: 






rterine Cavity after Sims's Operation. 



Ditto, after Simpson's Operation. 



" YIII. It removes stenosis perfectly, and in most cases permanently, 
since there is verv little teudencv to closure of the slight incision made. 



HH 



DILATATION. 



1G7 



I have bad to repeat the operation only twice in my practice, except in 
cases in which there was cicatricial tissue to be divided, as after imper- 
fect and partial closure following rupture of the cervix in parturition, 
or ensuing after Simpson's or Sims's operations. Here the operation 
will usually have to be repeated in a year or two, unless pregnancy 
should occur, an event not to be expected in such cases, as we have seen. 
" Finally, then, since my experience has shown that a diameter of 
one-fifth of an inch for the internal os, and of one-quarter to three- 
tenths of an inch for the external os, is sufficient in the treatment of 
stenotic sterility and dysmenorrhoea, I suggest the disuse of Simpson's 
and Sims's operations in the treatment of these conditions, and the sub- 
stitution of a milder, safer, and more efficacious method, of which, per- 
haps, my own is, however, only the forerunner. At least, further experi- 
ence in the line I have indicated will doubtless afford still more accurate 
conclusions." 

Dilatation. 

Dilatation, properly conducted, often accomplishes the removal of 
contractions by expansion, and straightens a flexed uterus sufficiently 
to render the flexion innoxious. It is done by instruments which 
can be introduced, closed, and, while in the cavity, opened so as to 
cause distension. Notable among these are Hunter's and Nelson's. 

Fig. 49. 




Himter's Dilator. 



When the obstruction is not very great these will frequently be suf- 
ficient, but if there is much constriction they should give place to 
other means which bear more uniformly on the w^iole inner circum- 



FlG. 50. 




Dr. Nelson's Uterine Dilator. 



ference of the cavity. I doubt if much improvement has been made 
on those introduced by Dr. Mackintosh, fifty years ago. He em- 
ployed metallic sounds of different sizes. 

His method of employing them was to introduce one large enough 



168 DYSMENORRHCEA. 

to produce some distension^ let it remain a few moments, and then 
one a little larger, and in the same waj succeed this by one still 
larger, until the dilatation is complete. This manner of dilating 
was repeated until the obstruction was removed. The introduction 
of the various forms of tents since the time of Mackintosh has di- 
verted the attention of the profession from this very effective method 
of dilating: the cervical canal. For the mode of usino- tents I would 
refer the reader to the subject Dilatation in another part of this work. 
Hank's hard-rubber dilators are elegant instruments, and may be used 
in the same manner as Mackintosh's. To use these dilators in the most 
effective manner the patient should be anaesthetized, placed in Sims's 
position, and the uterus exposed by his speculum. 

In the American Journal of Medical Science for January, 1867, I 
find the following summary, which I present to the reader without 
apology : 

^'Comparative Merits of Incision and Dilatation of the Mouth of the 
Womb in Cases of Dysmenorrhcea. — Professor D. Humphreys Storer read 
a highly interesting paper on this subject before the Boston Society of 
Medical Improvement. The large experience and sound judgment of 
Professor Storer not only entitle his opinions to a respectful considera- 
tion, but his conclusions to entire confidence. He says : ' From a some- 
what extensive employment of sponge-tents during the ten past years 
for the treatment of dysmenorrhcea and sterility, I have formed conclu- 
sions different from those of the gentlemen of whom I have spoken 
(Drs. Barnes, Baker Brown, Greenhalgh, and Sims). I have not uufre- 
quently been disappointed in the result hoped for. The local obstruc- 
tion has almost always been overcome by the long-continued, persevering 
employment of the dilator, but the opened canal does not always re- 
move the condition thought to depend upon its closure, — dysmenorrhcea 
and sterility still remain. I have, however, never seen the ill effects 
spoken of from the employment of tents. I cannot recall a single in- 
stance where more than a few hours' inconvenience has been produced; 
and in such cases the expanded sponge, when removed, has proved to 
have been originally much larger than it was supposed to be — showing 
that he who employs these tents should be acquainted with their un- 
compressed dimensions. My experience has taught me, then, that these 
contractions, however firm they may be, may almost invariably be over- 
come. The physician need not feel that the part is undilatable because 
the application of three, or five, or half a dozen tents does not overcome 
it ; in a case occurring in my practice, about a year since, eighteen 
sponge-tents were introduced at intervals of two and three days before 
the canal was opened. My perseverance was rewarded by the perfect 



169 



relief of the patient. I could point, were it necessary, to several cases 
where, after years of sterility, the sufferer has been relieved and borne 
children, and in the intervals of their childbearing have suffered nodys- 
menorrhoea. I have repeatedly seen cases of dysmenorrhcea remain re- 
lieved for years, and known no return. In a word, I have relied upon 
dilatation to relieve these affections, and whatever opinions may be ad- 
vanced by others, so long as I feel we have a remedy from which we 
can confidently expect relief, and very rarely observe any injurious 
effects, I shall feel it my duty to employ it.' 

" That cases do occur where the difficulty cannot be removed by dila- 
tation, there can be no question ; but ' that incision is the only efficient 
and permanent remedy (in most cases) for dysmenorrhcea,' I unhesitat- 
ingly deny. 

" Let us for a moment look at the method proposed. Those who ad- 
vocate it should of course be satisfied that it has superior claims over 
the means now employed. I have thought the ill effects produced by 
distension might be occasioned by want of care ; but those arising from 
incision may follow the operation of the most skilful surgeon who advises 
it, when the metrotome cuts through the walls of the inner os ; and Dr. 
Barnes states, to employ his own language. ' there is no doubt that the 
surgeon has actually cut through the substance of the uterus, and 
wounded the plexus of vessels outside ; hence severe and dangerous 
haemorrhage has ensued, and inflammation of the periuterine tissues.' 
And even supposing the operation should be successfully performed, it is 
acknowledged by Dr. Routh, one of its advocates, ' that such an amount 
of contraction frequently exists as to render it necessary to have a di- 
lating substance worn for a considerable length of time to prevent its 
perfect occlusion ;' and Dr. Williams observes that ' oftentimes no relief 
is afforded. He had seen a patient whose cervix uteri had been slit up 
on both sides, forming two large protruding lips, without affording any 
relief to the sufferer.' Where the external os has been almost cartilagin- 
ous to the feel, I have overcome the obstruction with the hysterotome ; 
but I have never attempted to divide the internal os. I cannot, how- 
ever, recall the instance where it was required." — Boston Medical and 
Surgical Journal, September 2d, 1666. 



CHAPTEE IX. 

METATITHMENIA (3hzaTcdr;fj.i [rrf/) ; OR, MISPLACED MENSTRUATION 
AND PERIUTERINE HEMATOCELE. 

The accident to whicli I apply the above terms is an effusion of 
blood in tissues around and above the uterus, the effusion being 
sometimes very extensive, at others limited to a small space. The 
effusion may take place in the vaginal wall, between the vagina and 
rectum, tearing up their connecting tissue, or in the posterior wall of 
the uterus, beneath the peritoneum, or between the peritoneal layers 
of the broad ligament beside the uterus, or in the peritoneal cavity. 
The mode of the accident varies somewhat, owing to the locality in 
which this blood is found. The blood is effused in interspaces 
beneath the peritoneum and elsewhere, as the effect of a rupture of 
some vessel ; but while the effusion may be, and, perhaps, generally 
is, the result of a ruptured vessel of the ovary, the blood sometimes 
also arrives in the peritoneal cavity from the uterus through the 
Fallopian tubes. We are not yet able to decide which of these cir- 
cumstances is the more common. 

This accident happens most frequently at the time of menstrua- 
tion, or very near it. As an accompaniment of menstrual congestion, 
the bloodvessels of the whole genital organs are greatly distended, 
and in certain cases this turgidity becomes too great for their capacity, 
and a rupture is caused at some particular place ; or, the cavity of 
the uterus being filled with a profuse flow into it, the blood regurgi- 
tates through the tubes into the peritoneum. It is not likely, how- 
ever, that any considerable effusions are thus caused, so that t^e 
sudden and copious collections sometimes observed must be accounted 
for upon the supposition that a small arterial twig has given way in 
the ruptured ovisac at the time of the escape of the ovum, and poured 
the fluid rapidly into the sac formed behind the uterus by the descent 
of the peritoneum. The instances I have observed were more fre- 
quently connected with cases of disordered menstruation, but I have 
also seen the accident in patients whose menses seemed normal. 

Dysmenorrhoea may be regarded as the most common deviation 
accompanying misplaced menstruation. 

There can be no doubt but that effusions of blood, in every respect 



MENSTRUATION AND ITS DISORDERS. 171 

similar to misplaced menstruation, are caused by the condition of the 
uterus and appendages in abortion after labor, and as the result of 
other causes of intense congestion ; but when so the modus in quo is 
precisely the same, the congestion being caused, not by the menstrual 
molimen, but by the congestion of pregnancy and morbid excitement 
which sometimes attend these two states, — rupture of a small vessel 
or reo-uro^itation beincr the immediate condition. 

Sanguineous collections arising in this way may be minute in size, 
but sometimes the quantity of blood is dangerously and even fatally 
large. The small collections are forced into places where distension 
is most difficult, as in the cellular tissue, while the large effiasions 
are met with in the peritoneal cavity. Immediately after the blood 
is extravasated changes begin to take place in it and the tissues occu- 
pied by it. Inflammation to a greater or less degree almost always 
is the result. In a mild o^rade the inflammation causes an effusion 
of serum, which augments the bulk of the accumulation and gives 
the appearance of much blood, when in reality there is but a small 
quantity. When this is the state of things, the disappearance of the 
tumor by absorption may be expected in a comparatively short time, 
and we often see it removed by absorption in a very few weeks. 

Dr. G. Bernutz has lately studied the pathology of uterine hsema- 
tocele, and presents his views in a series of interesting articles {Arch, 
de TocoL, March, April, and May, 1880). The most important con- 
clusions of this study are summarized by Bernutz as follows: 

" 1. Intraperitoneal uterine hsematocele may arise in two entirely dis- 
tinct and different ways. 

"2. In one case, which may be termed 'classic' hsemotocele, hsemor- 
rhage takes place from rupture of the products of extrauterine gestation, 
or from rupture of some of the internal organs of generation, or the 
escape of the blood which had distended the oviducts into the abdominal 
cavity, where a secondary peritonitis is set up by its presence, this 
inflammation leading to incapsulation of the bloody collection. 

" 3. In other cases the h^ematocele is the result of a primary pelvi- 
peritonitis, the haemorrhage occurring at a period more or less remote 
from the incipience of the serous inflammation. In this case the disease 
is a secondary manifestation of inflammatory action, and its true origin 
is found in the newly-formed membranes lining the pelvic peritoneum. 

"4. These neomembranous hseraatoceles may be symptomatic of 
various conditions. Thus they may indicate an acute pelviperitonitis 
in a woman who was previously attacked by a more or less severe 
inflammation of the pelvic peritoneum, or they may point to a repe- 
tition of former subacute inflammations, or, in fine, to a chronic pelvic 



172 METATITHMENIA. 

peritonitis of a particular kind. There are, therefore, two varieties of 
hsematocele symptomatic of pelvi-peritouitis, each of which has a patho- 
genesis of its own. 

"5. In the h^ematoceles denoting an acute or subacute peritonitis, the 
haemorrhage arising in the newly-formed membrane is from the outset 
rather profuse, being commonly determined by menstrual congestion. 
For this reason an intraperitoneal hsematoma becomes at once manifest. 
Frequently it becomes a matter of difficulty to distinguish between the 
two kinds of hsematocele unless the period of incipiency has been ob- 
served by the physician. Fortunately the practical importance of this 
fact is not very great, since the treatment is essentially similar in both 
varieties of the disease. In the second form of hsematoceles, which 
alone exactly corresponds to Virchow's description, the hsematoma is the 
result of scarcely suspected morbid action, which is very well indicated 
by the name of hoemorrhagic pachypelviperitonitis. Under the influ- 
ence of this chronic process the pelvic peritoneum is occupied by strati- 
fied patches of new-formed membrane. In this way it becomes thick- 
ened as it were, and slight haemorrhage takes place between the super- 
imposed lamelke, thus forming interstitial blood-cysts. These hsemato- 
celes are strictly analogous to similar tumors of the tunica vaginalis."'^ 

The intensity of the inflammation is frequently much greater, pro- 
ceeding through the stage of serous effusion to the production of 
fibrinous deposit. A hard tumor is the result. This again may 
remain for a longer or shorter time, and then very slowly disappear, 
or only be partially taken away, leaving a permanent hardness, or, 
what is not unfrequently the case, proceed to suppuration and dis- 
charge in some way. 

I have seen as many as two cases terminate fatally by the exhaus- 
tion of suppurative fever without the discharge of the contents of the 
tumor. When suppuration is fairly established by the inflammation 
thus arising, exulceration and evacuation follow as a general rule. 
The vagina is most frequently perforated by the ulcerative process, 
but the rectum, bladder, or uterus may serve as the conduit of dis- 
charge. If the inflammation is of an acute character, and the steps 
in the process of evacuation rapidly succeed each other, the character 
of the discharge will partake largely of a bloody quality; but should 
the time required by exulceration be considerable, pus will prevail in 
the composition. In any case, however, the discharge is a mixture 
of pus and changed blood. This last is sometimes very greatly 
changed, sometimes but slightly. In rare instances the peritoneum 

^ January, 1881, number of the American Journal of Obstetrics. 



SYMPTOMS. 173 

is inundated by rupture into its cavity of this mixture of pus and 
blood, and overwhelmed witli a general inflammation, soon resulting 
in death. I have seen cases of this kind, which were verified by 
post-mortem examination. 

After absorption in cases attended with the milder grade of inflam- 
mation, very slight traces, if any, can be found by examination of 
the patient. AVhen effusion of fibrin takes place, displacements, per- 
manent adhesions of the uterus and other parts, and deformity, will 
be left behind, slight or considerable, as the amount of deposit was 
small or great. These changes will, of course, be greater after the 
process of suppuration and discharge has been reached by the inflam- 
mation. Fistulous and tortuous openings may also embarrass the 
convalescence of the patient, or even by their long continuance ex- 
haust her. 

Symptoms. 

The symptoms vary in different instances. The attack is generally 
sudden and well marked. During the menstrual flow, or it may be 
just before or after, the patient is seized with severe pain in the hypo- 
gastrium or one of the iliac regions. Frequently there is also a sense 
of faintness, som'etimes slight, but often it amounts to complete syn- 
cope. In place of the faintness there are sometimes coldness and 
tremors. The pain becomes persistent, and, perhaps, less severe, but 
not unfrequently it increases for a considerable time and then gradu- 
ally diminishes. After the inception the pain usually spreads over 
the abdomen to the back and hips, and sometimes down the thigh 
and leg. As the pain becomes greater or extends over a greater space, 
febrile reaction is developed, generally moderate in grade, but occa- 
sionally excessive; the pulse becomes rapid, the heat considerable, 
and the patient complains of great depression and thirst. The abdo- 
men increases in size and becomes tympanitic, while there may be a 
distinct tumidity and hardness felt in one of the iliac regions; some- 
times the hardness extends over the hypogastric to the other ilium. 
This hardness and swelling may scarcely rise above the pelvic brim, 
but it not unfrequently is perceived extending as high as the umbili- 
cus. It is not much, if at all, tender to the touch. It is irregular 
in its outline also. In very rare instances the effusion takes place 
slowly, the symptoms are developed quite gradually, and the time of 
the beginning is not so definite, but the subsequent course is apt to 
be the same. 

After the symptoms are fully manifested, they pursue a course 



174 METATITHMENIA. 

corresponding to the grade of inflammation which is awakened by 
the effusion. In some cases the inflammation around the effusion is 
active and intense, and continues with severity until suppuration and 
exulceration end the process. 

Of course the fever is corresponding in grade and persistence, pass- 
ing through the high grade to hectic, attended with all its exhausting 
discharges. If the inflammation is less acute, the fever may be per- 
sistent for weeks, and sometimes for months, but of more moderate 
grade, until it gradually subsides, or slowly ends in suppuration and 
discharge. Fortunately, in the large majority of cases, the amount 
of the effusion is small, the grade of inflammation slight, and the 
duration but a few days or weeks. 

There are two ways in which individuals are rendered miserable 
by the frequent recurrence of this trouble. One is, when all the 
symptoms subside entirely for months, and then return. The tumor 
entirely disappears, the inflammation is wholly gone, and the patient 
feels that she has fully recovered her health, when, suddenly, during 
a menstrual flow, she is again seized with pain, swelling, fever, etc., 
which again subsides to be repeated more or less frequently. I have 
a patient who has suffered attacks of this sort perhaps twenty times 
in the last six or seven years, in whom the tumors have at different 
times been mistaken for ovarian or uterine tumors. In the other way 
the subsidence is only partial; there is all the time some tumidity, 
some inflammation, and more or less sympathetic suffering, with occa- 
sional severe returns. More blood is effused, the tumor is increased 
in size, and the inflammation intensified, and all subside to a partial 
extent and return again. 

When the tumor is much inflamed and suppurates, it may suddenly 
discharge through the vagina ; all the urgent symptoms readily sub- 
sides, and the patient becomes convalescent. Again, the discharge 
is sometimes slow and difficult, the relief is imperfect, and a pro- 
tracted convalescence the result. But sometimes, after a course corre- 
sponding to the above description, sudden and general peritonitis is 
lighted up by extension of inflammation from the sac, or a discharge 
of some of its contents into the peritoneal cavity. 

The discharge is generally fetid and highly irritating, consisting of 
partially decomposed blood, pus, and ichor. It is always offensive 
compared with discharges from an ordinary abscess. I have seen one 
or two instances in which the general symptoms were not manifested 
at all, nor did the pain amount to anything more than an inconveni- 
ence, not very difficult to bear. 



DIAGNOSIS. 175 

It is iuteresting to observe the effects of tin's misplaced menstrua- 
tion upon the flow per vlas naturales. Occasionally no effect seems 
to be produced, the flow being natural in quantity and duration ; in 
fact, it is just at the time of the cessation of the discharge that effu- 
sion into the tissues takes place, but at other times there continues for 
many weeks a constant stillicidium of blood. Or, occasionally, — 
when the menses occur during the course of the symptoms, — the 
amount of discharge is very much increased. I knew one patient 
that had a constant slight sanguineous discharge from the vagina for 
six months, and at the regular menstrual periods copious haemor- 
rhages. In some cases the flow is more scanty than usual. 

Diagnosis. 

There are several conditions with which this sanguineous effusion 
may be confounded, if some caution is not observed. Inflammation 
of pelvic cellular tissue, or pelvic abscess, is the one most likely to 
be mistaken for metatithmenia, or this last for the first. And as I 
have already shown abscess is sometimes the result of misplaced 
menstruation, the effusion in the tissues exciting intense inflamma- 
tion, which proceeds to the stage of suppuration. 

In cellulitis the inflammation is not ordinarily ushered in by the 
same suddenly occurring acute pain and faintness. Chilliness and 
fever are more marked from the beginning, the pain usually com- 
mencing after the fever has begun, or, at least, increasing after the 
fever is established. The tumor above the linea ilio-pectinea is not 
perceptible for many hours, oftener one or two days ; it is extremely 
tender, and even in its outline. 

In metatithmenia the tumor is observed in a few hours, and is not 
so very tender to the touch. It may be handled and pressed upon 
much more freely than the tumor of simple inflammatory origin. If 
examined per vaginam the inflammatory hardness and swelling is 
very firm. It is usually lower down and more to one side. The 
tumor from sanguineous effusion is quite elastic at first, and presents 
an edgelike projection down behind the uterus, entirely below the os 
and cervix. The finger may be pushed up between the cervix and 
the tumor, and the thick convex edge of the latter reminds one of a 
thick cake. There is very little tenderness, and vessels may almost 
always be felt pulsating over this projection. I need not say that 
this is never the case in the early stages of cellulitis. The vessels in 
this last are obliterated by fibrinous and serous effusion. 

If inflammation of a high grade speedily follows the effusion of 



176 METATITHMENIA. 

blood in the tissues, the symptoms of the two may be so intimately 
blended as to make it doubtful how the tumor began, and, in fact, it 
may be converted into pelvic abscess. 

Tumors of the uterus, under certain circumstances, may be con- 
founded with the tumor of sanguineous eifusion ; but their firmness, 
the want of conformity to the shape usually assumed by this last, the 
enlargement of the uterine cavity, our ability to isolate them by the 
fingers and probe, their gradual, unperceived growth, and their mo- 
bility, will almost always suffice to make the distinction manifest. 

From ovarian tumors it may be distinguished by the more regular 
outline, fluctuation on percussion, less grave symptoms, gradual de- 
velopment, absence of the projecting edge behind the uterus, the 
want of the beating vessels, etc., in ovarian growths. 

Displacements of the uterus may always be made out with great 
certainty by introducing the probe into its cavity to ascertain the di- 
rection of the fundus, and correcting its deviations. Hence the diag- 
nosis need not be long embarrassed by any question in reference to 
them. Retroversion of the impregnated uterus is constantly attended 
with great urinary distress, while metatithmenia seldom is. 

Extrauterine pregnancy, perhaps, in some instances, more nearly 
resembles it than any other, but the enlarged and flaccid cervix, open 
OS, dark color, and enlarged cavity, in this sort of pregnancy, and 
their absence in the accident we are considering, will suffice to dis- 
tinguish between them. 

Prognosis. 

The dangers to be apprehended in uterine hsematocele arise from : 
1st, the shock of the effusion in the peritoneal cavity, which, however, 
is not generally considerable; 2d, fatal exhaustion from the amount 
of effusion in the abdominal cavity; and, 3d, inflammation and its 
effects. From inflammation we may fear death, permanent damage 
to the organs about the pelvis, and great suffering. Very few pa- 
tients escape without protracted suffering, often for weeks, and some- 
times months. 

Damage to a greater or less degree frequently follows the displace- 
ments, adhesions, perforations, and thickening of the uterus, vagina, 
rectum, and bladder. The exhaustion of protracted febrile excite- 
ment; the perspiration, diarrhoea, and vigils not very seldom wear 
out the vital resistance of the patient, who is often of a very delicate 
constitution; or sudden and violent inflammation of the peritoneum 
overwhelms and destroys her. 



TREATMENT. 177 

The prognosis iu any given case will be governed by the intensity 
of the symptoms and the comparative strength of the patient. If 
the amount of the effusion be never so large, and there be but little 
inflammation, the prognosis is more favorable than if the effusion be 
small and the inflammation great. In fact, we may with great pro- 
priety form our prognosis by the amount and intensity of the inflam- 
mation alone, as it is almost the only source of danger. 

As before observed, a cause of death, though not frequent, should 
nevertheless be mentioned as influencing the general subject of prog- 
nosis in misplaced menstruation, viz., a fatal amount of extravasation 
of blood in the peritoneal cavity. More than one case is recorded in 
which there was fatal prostration, coming on and pursuing its course 
in a few hours, which, when examined, revealed, as the source of an 
extensive and copious haemorrhage, the ruptured twig of an artery 
on the ovary. Of the many cases that come within our observation, 
however, the number that thus prove fatal are extremely few. 

Treatment. 

The three great facts of this accident — haemorrhage, pain, and in- 
flammation — afford us sufficiently plain indications for treatment. 
It is very seldom that we are sent for, or in any way see these cases, 
until after the haemorrhage has exhausted itself or been stopped by 
backward pressure, after filling up the space into which the bleeding 
takes place. Should we, however, meet with an instance during the 
haemorrhagic stage, it would be very proper to make use of ice to the 
pelvic region, perfect quiet, and astringents internally, until the effu- 
sion ceased; but, as I said before, such opportunities seldom offer 
themselves. The cases as we ordinarily see them have proceeded 
through this stage ; the effusion, in fact, is generally accomplished in 
a few moments, or at most in very few hours. When we see the 
patient, she is either suffering with pain and prostration or coldness, 
the primary effects of the haemorrhage; or pain, fever, and inflam- 
mation, and our treatment will be conducted according to the con- 
ditions in these respects. Our resources in the first condition will lie 
in the use of opium or other anodyne, to relieve the pain as much as 
may be necessary, and if the prostration or chilliness is considerable, 
to stimulate sufficiently to establish equilibrium in the circulation, 
but not febrile reaction. In very many cases it will be sufficient to 
keep our patient quiet, and place her upon moderate anodyne treat- 
ment, good nourishing diet, and perhaps, after the first week or two, 

12 



178 METATITHMENIA. 

tonics, and she will slowly rally from the first shock, absorption of 
the blood will result, and she soon will recover her health. In these 
moderate cases we cannot be too careful not to overdo the treatment. 
The patients will generally recover spontaneously in a few days or 
weeks. 

But another class of cases occur, as I have already said, in which 
inflammation very soon succeeds the sanguineous effusion. A knowl- 
edge of the mischief which this inflammation brings about should 
make us prompt in meeting it with appropriate remedies. If the 
inflammation runs high, adequate antiphlogistic measures will be 
indispensable to a favorable course. An active cathartic of calomel 
and jalap or some other alterative cathartic should begin at once, 
while at the same time, if deemed advisable on account of the force 
of reaction, we may apply a dozen or twenty leeches. These may be 
followed by the tincture of veratrum viride, in doses of two drops 
every hour, until the pulse is brought down to its natural frequency 
and volume, if not below these conditions, and then continue its use 
in less doses, or the same less frequently repeated, for some time. 
According to my observations, the most of adults will be held at this 
point by taking as little as one drop an hour ; some will require more 
and some less. The energy of this antiphlogistic course must be 
graduated by the force of inflammation ; but few cases will require 
as much as is described here. Should the inflammation advance to 
suppuration, the remedies required will be supporting; at first, 
sulphuric acid and quinine, and afterwards these with wine or other 
stimulants, nourishing diet, etc. These cases are often so protracted, 
the patients are so much prostrated, and suffer so much pain, that 
great skill will be called for to adapt the anodynes, tonics, and nutri- 
ents to the various conditions of the patient for so long a time. 

A question associated with the progress of inflammation, and one 
of great importance, is the propriety of evacuating the fluid. To 
evacuate the blood soon after its extravasation would seem to remove 
the cause of inflammation, and thus avoid it. To say that an early 
evacuation of the effusion would never be proper is perhaps to assume 
an extreme position, and there may be cases where such evacuation 
,is advisable, but I think the number requiring it must be very few. 
Indeed, I should fear inflammation, from the sudden discharge of a 
large amount of blood from the peritoneal cavity, almost as much as 
if it were allowed to remain in it. There is another condition in 
which an operation for discharge of the contents of the tumescence 
is less a question of doubt, viz., when pus has become mixed with 



CHRONIC RETROUTERINE HEMATOCELE. 179 

the blood, on account of inflammation. It is very important in some 
instances to puncture and discharge the fluid. When the patient is 
being worn out by the protracted course of the disease, and the per- 
spirations and diarrhoea which so often attend it, we must interfere 
surgically for her relief. And again, when the fluid is increasing, 
and the tumor rising in the abdominal cavity, without showing any 
disposition to "point" in the pelvis, or any other place where it is 
desirable to have it do so, there is danger of the discharge of the pus 
and blood in the peritoneal cavity by rupturing the sac above, and 
we must anticipate it by choosing the place and mode. When we 
have determined to relieve the distension by puncture, we ought to 
use an exploring-needle or trocar to ascertain the contents before 
evacuating them. After being satisfied by this corroboration of our 
diagnosis, we may plunge a large trocar, or even a knife, into the 
most dependent part of the tumor. This point will almost invaria- 
bly be immediately behind the uterus, but occasionally it will be at 
the side of the pelvis. 

After free puncture, either with the trocar or knife, the discharge 
readily takes place, and the patient immediately experiences great 
relief If the puncture is made to remove the blood before inflam- 
mation has begun, the evacuation may be more difficult, as it is often 
coagulated ; in that case the opening must be made large with a knife, 
and if the blood does not easily flow, the finger may be introduced 
to break up the clots aud facilitate their expulsion. After the con- 
tents are thus expelled as near as can be, they sometimes reaccumu- 
late and are again discharged, and repetitions of these processes lead 
to still more chronic suffering, until the patient becomes a perma- 
nent invalid, or dies from such long-standing exhaustion. We may, 
with a good deal of certainty, cause contraction, granulation, and 
obliteration of the cavity, by injecting it with iodine, wine, or other 
irritant. The best way to secure efficiency in injections is to intro- 
duce through the fistulous opening, or one made for the purpose, a 
small flexible catheter, so as to reach the bottom of the cavity and 
throw the fluid through this tube. We thus place the fluid used in 
full strength in contact with the walls of the cavity, while the injec- 
tion thrown out of a common syringe will mix it up with the con- 
tents of the sac, and thus dilute it. 

Chronic Retrouterine Hcematocele. 

I have met with a considerable number of hsematoceles that did 
not terminate by absorption on suppuration, but remained in a latent 



180 METATITHMENIA. 

condition, sometimes for years, and then became the subjects of change 
in their contents Tvhich rendered radical treatment indispensable. 
In the history of many of these cases the essential facts necessary to 
lead to a rational diagnosis are lost. 

The time when the eifusion occurred is so remote that many of the 
svmptoms have been forgotten, or taking place contemporaneously 
with an abortion, or paroxysm of dysmenorrhcea, the symptoms of 
haematocele were so blended with those of the other condition that 
thev escaped notice. Xot unfrec[ueutly our attention is called to these 
cases in the hands of inexperienced practitioners without being recog- 
nized, for a long time passing for retroversion of the uterus. 

After a greater or less length of time some of them undergo rapid 
increase of size, from an accumulation of serum, while others grow 
more slowly, but still become decidedly inconvenient tumors. 

One of the former kind has quite recently come under my notice. 
The patient was twenty-four years of age, the mother of two children, 
enjoyed good health until two years since, when she had, without 
any assignable cause, severe flooding, and was thereafter confined to 
bed for several weeks. She gradually recovered sufficiently to very 
poorly attend to her household duties. She did not have the advice 
of an experienced practitioner until three or four months before she 
came under my notice. Her physician at that time discovered a 
retrouterine tumor that extended above the brim of the pelvis, with 
the most prominent elevation on the right side, where it arose one 
and a half inches above the pubis. A^'hen first observed the lower 
portion of the tumor extended about an inch below the cervix uteri. 
From that time the tumor grew perceptibly until, at the time she 
came to me. the posterior cul-de-sac was very tensely distended. The 
lower end of the tumor was elastic, but too tense for undoubted 
fluctuation. The upper part of the tumor remained as above de- 
scribed. Dr. D. T. Xelson examined the patient on the same day, 
Thursday, the 24th of February, 1881. We requested her to call 
again on the 27th of the same month, or three days later. When 
she came again for examination we were both astonished at the rapid 
increase in size manifested at the lower end of the tumor. The lower 
end of the tumor was so much larger and descended so far down as 
to begin to separate the external labia. The question with us was 
between a fungus or malignant tumor, behind and attached to the 
uterus, or an old haematocele. She was at once admitted into the 
Woman's Hospital, and the next day a small trocar was thrust into 
the tumor for exploratory purposes. 



CHRONIC RETROUTERINE HEMATOCELE. 181 

A large amount of reddish serum was ejected with great force 
through the canula. I then made a small incision by the side of the 
trocar, through which I introduced my finger, and enlarged it so that 
I conld introduce two fingers into the cavity. The fingers at once en- 
countered large deposits of macerated fibrin clinging to the wall of 
the cyst. These were separated as far as practicable, the cavity thor- 
oughly washed out, and several pledgets of cotton saturated with tinc- 
ture of iron introduced. The serum contained albumen and the 
coloring matter of blood. 

A very remarkable case, with the commencement of which I was 
cognizant, is recorded in the first volume of the Transactions of the 
Americam Gynaecological Society, by George H. Bixby, M.D., of 
Boston. 

I saw the patient and attended her for three or four months after 
the eflPusion occurred and diao;nosed retrouterine hsematocele. Duriuo^ 
the time I attended her the tumor decreased decidedly, and I fully 
expected it to be entirely absorbed. The patient, as Dr. Bixby ob- 
serves, passed out of my care, but remained in Chicago, where I 
could know somewhat of her condition. 

She was an invalid during the whole seven years intervening be- 
tween my attendance and the time she went to Boston. As she was 
leaving Chicago for Boston she desired me to make an examination. 
The tumor was easily recognized at that time, but was not large. I 
subjoin Dr. Bixby 's description of the case after she went to Boston : 

"Mrs. H , aged thirty-nine, a resident of Boston, consulted Dr. 

Mack, of St. Catharine's, Ontario, for an obscure pelvic tumor. On the 
following day I was called in consultation. The patient was of dark com- 
plexion and nervous temperament. Menstruation, which first appeared 
at eighteen and recurred at intervals of three weeks, was scanty and 
painless. In her youth she was unusually fond of outdoor sports, and 
later in life indulged in horseback exercise. She was married at twenty- 
one, and supposed she miscarried two years later. Seven years pre- 
viously, while under the care of Professor Byford for uterine disease, 
she became the subject of hsematocele, but shortly after passed out of his 
hands. For two years Mrs. H. had been suffering from a peculiar pain 
in the left ovarian region, and also from renal and vesical derangements. 
She described the pain as occurring in paroxysms, at first light, gradu- 
ally increasing in intensity until almost insupportable, then as gradually 
subsiding. Soon after the occurrence of the above symptoms her attention 
was directed to a tumor the size of a small orange at the seat of pain. 
In the dorsal position, with the limbs flexed, percussion gave evidence 



182 METATITHMENIA. 

of a well-defined dulness in the left ovarian and siiperpubic regions ; by 
bimanual palpation unmistakable fluctuation. The uterus was fixed, 
and lateroverted to the right ; its cavity two and one-half inches in 
depth. Exploratory puncture (through Douglas's fossa), with a small 
trocar by Dr. Mack, confirmed the existence of fluid. Three pints of a 
light straw-colored serum were withdrawn by aspiration, which completely 
emptied the cyst. The result of an analysis by Dr. Fitz, of Boston, was 
as follows : ' A clear, light reddish-brown, odorless, slightly alkaline fluid, 
sp. gr. 1020; absence of sediment ; abundance of albumen, it becoming 
solid by boiling ; abundant chlorides and sulphates. Microscope reveals 
numerous oil-globules, a few round cells with large nuclei and a small 
amount of granular protoplasm ; an occasional granular corpuscle. If it 
be a question between ascitic or ovarian, the latter is probable.' Notwith- 
standing this result we were disposed to consider this case one of encysted 
dropsy of the peritoneum following hsematocele. Being now intrusted 
to my care she was ordered rest in bed, no treatment. Not the slightest 
reaction followed the operation, and in the course of three weeks she 
resumed her ordinary duties. 

Dr. Mack was disposed to attribute much of the pain as well as the 
renal derangement to pressure upon the nervous filaments of the tissues 
in the vicinity of the cyst. The description of the pain and the renal 
and vesical symptoms were at least suggestive of some interference with 
the functions of the ureter by pressure from the cyst. 

" The following letter from Dr. Byford, received since the operation, 
tends to confirm the diagnosis : 

'' ' Dear Doctor : I can emphatically indorse your diagnosis and proposed treat- 
ment. In my own practice I have met with but two cases of serous accumulation 
after hematocele. One was cured by a single tapping with the aspirator, the other 
by establishing a permanent drain from the cavity. In the last case reaccumulation 
took place. I then punctured with a large trocar, and passed through the canula 
a flexible catheter, and left it in position. The cure was effected in about three 
weeks.' " 

Diagnosis. 

The diagnosis of these old hsenaatoceles is not always easy. The 
history, if the patient can intelligently trace it, will often lead to a 
strong suspicion of the character of the tumor. The primary attack 
may date back several months, and sometimes as many years, and 
may have been distinguished by symptoms arising from the continued 
presence and occasional augmentation of the tumor, indicative of some 
form of pelvic disease. Not unfrequently, however, the commence- 
ment is so obscured by attendant circumstances as to evade the most 
diligent inquiry, when we shall be obliged to depend upon recent 
developments and physical examination for a diagnosis. 



TREATMENT. 183 

In many cases the patient will have suffered a long time from pelvic 
symptoms, and be aware of the existence of a tumor. The tumor 
is often mistaken for grow^ths, as ovarian or uterine tumors, and even 
extrauterine pregnancy. In hematocele the tumor is situated behind 
and adherent to the uterus. The uterus is pressed strongly forw^ard 
and upward, and generally to the right side, so that the fundus may 
be felt above the right ramus, itself simulating a tumor. Generally 
the top of the hsematocele may be recognized by pressing the hand 
down into the brim of the ])elvis, while the lower end will be found 
to fill up the cul-de-sac of Douglas, and distend it very greatly. 
The distension is especially downward, reaching occasionally as low 
as the external organs. 

I should regard the forcible downward distension of the cul-de-sac 
with fluid as a very important, if not a distinctive sign of chronic 
hsematocele. The upper part, or fibrinous covering of the hsemato- 
cele, is inelastic and does not permit of distension in that direction, 
while the w^alls of the retrouterine pouch is elastic and permits dis- 
tension. An ovarian tumor, a tumor of the lateral ligament, or an 
extrauterine pregnancy develops upward instead of downward. 
While any or all of these may be felt to occupy the cul-de-sac they 
do not forcibly distend it downward. Instead of displacing the 
uterus upward as well as forward, they displace it forward at first, 
and afterwards downward. 

The hardness and more globular shape of a fibroid tumor, situated 
in the retrouterine space, will generally enable us to distinguish it 
from an old hsematocele. An abscess is seldom situated immediately 
behind the uterus, and when it is there is generally so much hardness 
around the presenting fluid as to make the distension irregular, aside 
from the usual tenderness. 

When the diagnosis cannot be made in any other way the tumor 
may be aspirated. The fluid drawn from an old hsematocele is well 
described in Dr. Bixby's case. The coloring matter of the blood is 
always noticeable. 

Treatment. 

The proper treatment of the chronic hsematocele consists in evacu- 
ating it, draining the cavity, and frequent injections of some disin- 
fectant solution, — the carbolic acid or permanganate of potash. When 
a sufiicient amount of fluid is removed for diagnostic purposes the 
trocar or aspirator needle may be taken as a guide for the incision. 
The incision should be made in the most prominent part of the tumor 



184 METATITHMENIA. 

large enough to admit the finger. The index finger should be intro- 
duced through it, and be made to tear a large opening into the sac. 
The opening must be large enough to admit two fingers freely into 
the cavity. Large deposits of the fibrin of the blood will be 
found adhering to the inner wall of the sac. The removal of 
these coagula of fibrin is very important, for if allowed to remain 
they will undergo decomposition, and thus be the source of sepsis. 
The large opening I have recommended has the advantage of per- 
mitting the free use of the fingers for this purpose and the efficient 
cleansing of the cavity by injections. When carefully performed this 
operation causes little or no shock, and the patient usually recovers 
in two or three weeks from the effects of the evacuation. It requires 
several months for the sac itself to be removed by absorption. 
Eventually, however, it disappears to such an extent as not to be 
recognizable by an ordinary vaginal examination, and with proper 
care the patient speedily recovers her usual health. 



I 



CHAPTER X. 

CHANGE OF LIFE— MENOPAUSE AND SENILITY. 

At the period when woman ceases to menstruate various changes 
in her system occur, which constitute what is termed " change of life." 
•The peculiar anatomical feature noticeable is progressive atrophy of 
the ovaries, uterus, and usually of all the other female organs, in- 
cluding the mammary glands. 

Dr. Tilt, in his excellent work on the Change of Life, says: '^Pu- 
berty and the change of life are caused by anatomical changes, the 
one by ovarian evolution, the other by ovarian involution.'^ I should 
say these two conditions were accompanied by, instead of caused by, 
the ovarian evolution and involution. 

The change of life is an important epoch in a woman's existence, 
for if not, as Dr. Tilt thinks, the cause of many diseases, it is con- 
temporaneous with a number of the most dangerous affections, and 
certainly modifies very materially the course of others. When not 
accompanied by disease it is normal, and usually leaves the Avoman, 
to say the least, in no worse condition than before it occurred. Gen- 
erally she becomes more vigorous after it, and her prospects for life 
and health are increased. 

The change of life is gradual, requiring from one to^eight, or even 
ten years for the processes of involution and changes in all the body to 
take place. The average of the menopause is forty-five years. "While 
it may not always be the case I think a very early or very late men- 
opause is abnormal in other respects than time. The cases that come 
about very early in life are much more frequently than otherwise caused 
by pathological conditions. Peculiarity of organization is the only 
way to account for the remainder. Such instances as have fallen 
under my observation were without exception preceded by diseases of 
the uterus and probably of the ovaries. I say probably, because the 
ovarian affection cannot always be diagnosticated with certainty. 
The late menopause I have not met with as often, and I have not 
been so clearly convinced of the condition of the patients as in the 
former. In such cases as I have noticed most of the women seemed 
to be peculiarly vigorous, though sometimes I have thought the long- 



186 CHANGE OF LIFE — MENOPAUSE AND SENILITY. 

continued functional activity of the genital system appeared to depend 
upon chronic hypersemia, caused by tumors, congestion, or inflamma- 
tion. 

Simple cessation of the menstrual return is not the change of life. 
When the menses cease from a failure of the general j)Owers, the 
term will not apply. 

The cessation of the menses does not always take place in the same 
way. Sometimes it occurs suddenly, with no change in the quantity, 
quality, or periodicity up to the last return, and with no premonitory 
symptoms. At other times a change in the periodicity of the men- 
strual flow occurs as a premonitory symptom of its cessation, the* 
intervals in some cases being irregular, in others steadily decreasing 
in time until complete cessation occurs. 

Not unfrequently the menstrual discharges grow progressively less 
for ten or twelve years before they completely cease. By this method 
the change of life becomes an accomplished fact only after a compara- 
tively protracted transitional period. Sometimes a severe hsemorrhage 
is succeeded by the menopause. 

IN^umerous other methods exist by which this important change is 
brought about ; those which I have mentioned are the more common 
ones. 

There are probably no reliable symptoms, not immediately con- 
nected with the cessation of the menses, to indicate the approach or 
even the progress of the change of life if the woman is in a perfectly 
healthy condition. The change, when a healthy one, is so gradual 
that the various organs and the nervous and vascular systems have 
ample time to accommodate themselves to the difference in the func- 
tions of the sexual system. 

Does the change of life give origin to the diseases, or to any of 
them, occurring at that time? My opinion is that it does not. I 
believe them to be merely coincident. Fibroid tumors of the uterus 
and cancer of various organs do frequently occur about the time of 
the menopause, but they also are often met with both before and after 
that period. The long list of diseases and symptoms enumerated by 
Dr. Tilt are only evidence that the woman was diseased before, or 
became so at the time, from other causes, instead of indicating the 
change of life as the cause of them. 

Yet there is little doubt that the progress of existing disease is 
modified by the changes in the circulation, nutrition, and nervous 
energies which occur at the change of life. In different parts of the 
present work I have alluded to this in describing the diseases in per- 



CHANGE OF LIFE — MENOPAUSE AND SENILITY. 187 

sons of different ages. Women undergoing the change of life who 
are not tlie subject of disease require no special management or treat- 
ment. It is well to have them as nearly as possible cured of the 
inflammations, congestions, and displacements which afflict them, as 
that will cause the process to be more easily and naturally accom- 
plished. However, I think we need not fear that the change of life 
will be disastrous either as a cause of disease or by injuriously modi- 
fying those already existing. As elsewhere stated, we usually expect 
chronic inflammation and its consequences to be benefited, if not en- 
tirely cured, by senile involution of the organs of generation, and we 
also often find the fibroid degeneration and growths of the uterus 
arrested in their progress by the same change. In all respects, when 
not complicated, we may expect the menopause to be a favorable 
crisis in woman's life; and even when contemporaneous with dis- 
eases, it is much more likely to beneficially influence their course 
than cause them to be aggravated. In all my expressions on the 
subject I have steadily kept in mind the fact that the menopause is 
but an incident among the processes whicli go to constitute the change 
of life. Senility in woman, after a complete change of life, is a state 
in which she is free from the embarrassments connected with the 
active sympathies of the genital organs. Her diseases are more sim- 
ple and less liable to become complicated. They are no longer female 
in their nature but fall into the category of common diseases. Ex- 
ceptions occur to this statement. We do, though rarely, find some 
of the diseases, such as metritis, and even ovaritis, etc., commencing 
in old age. When they do originate in this stage of life, as the genital 
organs are in a state of feeble vitality, and the general system is in- 
capable of exerting the same recuperative force as in earlier life, we 
may expect them to be both more obstinate in their resistance to treat- 
ment and more disastrous in their course. 



CHAPTEK XL 

ACUTE INFLAMMATION OF THE UNIMPKEGNATED UTEEUS. 

Causes. 

Acute inflammation, not arising from specific causes, generally 
affects the fibrous portion or substance of the walls of the uterus. 
It almost always, if not quite, pervades the whole of the organ, the 
fundus, body, and cervix. Exposure to cold is the most frequent 
cause. The cold may be applied to the general surface when the 
uterus is in a state of turgescence from menstrual congestion, sexual 
excitement, or incomplete involution after labor or abortion. The 
same agent acting upon a portion of the surface, as the feet and legs, 
under a similar condition of the organ, may give rise to the same 
disease. It is not likely that cold, however applied, would be a suf- 
ficient cause, but for the predisposing condition I have mentioned. 
The excitement of excessive sexual indulgence may be carried so far 
as to cause a moderately acute inflammation of the substance of the 
uterus, as also blows upon the abdomen, etc. 

It is not a very frequent disease, and yet I do not think it can be 
regarded as an infrequent affection. 

Symptoms. 

In speaking of the symptoms of the dispase, I wish the reader to 
bear in mind that their intensity will vary from a mildness that will 
scarcely confine the patient to her couch to a very severe and grave 
disease, almost overwhelming the nervous system, with delirium and 
convulsions, and calling the stomach into excruciating sympathy with 
it. In considering the subject, I wish to be understood as attaching 
more importance to the suddenness than to the intensity of the attack 
in determining the nomenclature. 

It is somewhat owing to the exciting cause, as to the symptom 
which is likely to usher in the attack. If the cause is a moderate 
one, as excessive sexual indulgence, pain will generally begin some 
time before the general symptoms. If the cause is cold suddenly 
and extensively applied to a menstruating patient, chills and rigors 
may precede the pain. However that may be, when the case is fairly 



PROGNOSIS — DIAGNOSIS. 189 

developed there is fever, aching in the back, pain in the head and ex- 
tremities, flushed face, and furred tongue. In addition to these general 
manifestations there is local pain, indicating the organ affected. This 
pain may be confined almost entirely to the sacrum and the lumbar 
region if the inflammation is moderate, but generally there is pain in 
the pelvis behind the pubis, or in one or both iliac regions. Some- 
times the pain radiates in several directions up the abdomen, down 
the thighs, and around the body. The pain is usually of a dull 
aching, but sometimes of a sharp character. In addition to these 
symptoms indicating inflammation in some of the pelvic organs, the 
nervous system is often affected with hysterical symptoms, convul- 
sions, coma, laughing, crying, or unreasonableness of some kind. I 
should have mentioned among the local symptoms dysuria and dif- 
ficult and painful defecation. Should the peritoneal covering become 
involved there is swelling and greater or less tenderness of the ab- 
domen. Xausea and even vomiting are not infrequent symptoms. 

After a week or more of this kind of suffering the symptoms gradu- 
ally subside, and the patient slowly recovers her usual health ; or 
sometimes the subsidence of the pains is not complete, and she con- 
tinues to suffer with a chronic form of inflammation. The termina- 
tion is almost always in resolution or the chronic form of the disease. 
Possibly, in some exceedingly rare instances, the force of inflammation 
is spent in some circumscribed locality, and it proceeds to suppura- 
tion. I have lately seen an instance of this kind where the suppura- 
tion was in the anterior lip of the cervix. 

Prognosis. 

The termination is so frequently in resolution or a moderate form 
of chronic inflammation, that w^e may almost always expect complete 
or partial recovery. Death probably never results in uncomplicated 
cases of acute metritis, but unfortunately we occasionally meet with 
grave and even fatal peritonitis, apparently resulting from extension of 
the disease from the uterus. It has been my misfortune to have lately 
met, in consultation, with two instances of this sort. Although the 
prognosis is favorable, as a general rule, so far as the recovery of the 
patient from the attack is concerned, it is not so favorable for the 
complete re-establishment of health, as the patient is likely to be 
affected with chronic inflammation in the body or cervix. Not un- 
frequently we trace chronic inflammation back to a moderate attack 
of the acute. 



190 ACUTE INFLAMMATION OF THE UNIMPREaNATED UTERUS. 

Diagnosis. 

Inflammation of the cellular tissue beside the uterus, metatithmenia, 
rectitis, or cystitis, cause symptoms which may be mistaken for me- 
tritis. When doubt exists it may be easily and certainly solved by a 
dio^ital examination. If the bladder is the seat of disease, the ten- 
derness complained of by pressing it between fingers in the vagina 
and others above the pubis will be sufficient proof ; pressure may be 
made upon the rectum by including it between the introduced fingers 
and the sacrum. The inflammation at the side of the uterus, or 
cellulitis, causes tenderness and hardness close to the iliac bones 
on the side, and the hardness seems to be continuous with the bones. 
The greatest tenderness is therefore close to the side of the pelvis. 
In all these cases the uterus may be touched, provided it is not 
moved so as to press upon the inflamed part or organ without causing 
pain. If it is the seat of inflammation the tenderness will be con- 
fined to that organ, while all the rest are free from it, and may be 
handled freely. We should not forget that all these organs may be 
implicated in one great mass of acute inflammation, and all the pelvic 
contents be intolerably tender to the touch. In an examination to 
diagnosticate inflammation of the uterus, I need hardly say that a 
resort to instruments is unnecessary. 

Treatment. 

The intensity of the inflammation will govern us in the activity of 
treatment. If it is not attended with great pain or febrile reaction, 
although our remedies must be the same, there is no need of using 
them with the same energy. We should, however, bear in mind the 
great likelihood of leaving the chronic form behind, and be diligent 
in our medicinal and hygienic appliances, until every vestige is gone, 
when practicable. If the attack is moderate, it may sometimes be 
interrupted in the beginning, by measures to induce a copious per- 
spiration, more particularly if caused by an exposure to cold. Even 
a smart attack may sometimes be relieved by a large dose of opium 
and a steam-bath, used within a few hours after the commencement 
of the symptoms. After the symptoms have become fairly established 
and have lasted for twenty-four hours, we must not expect to find 
immediate relief, and should begin the systematic use of antiphlogistic 
treatment. In the subacute form, a brisk cathartic, foot-bath, and 
fomentations over the uterus, should be followed by tart, antimony, 
muriate of ammonia, and calomel. 



INFLAMMATION OF MUCOUS MEMBRANE OF THE UTERUS. 191 

Perfect quietude should be enjoined also, and rest at night may 
be insured by giving one grain of calomel, with twice the amount 
of opium, in a pill at bedtime. Continued for five or six days 
this will generally induce slight mercurial eifect, when the pain and 
other symptoms will pretty surely subside. If it does not do so, a 
blister over or a little above the pubis will aid in banishing them. 
If the attack is severe, we ought to add to the above remedies the 
more immediately depressing. The patient may be bled from the 
arm until a decided impression upon the pulse is produced, or we 
may apply from ten to twenty leeches to the vulva and groins, as 
the depletant measure. In the country, where leeches cannot be 
had, scarification and cupping can be profitably substituted for them. 
Should arterial excitement be high after the depletory measure, the 
tinct. of verat. viride in doses from four to six drops every four hours, 
with the ammon. mixture, will be an efficient adjunct to our remedial 
measures. The calomel should be withheld as soon as its specific 
effects are produced. 

I should not discharge the obligation I feel to the student in the 
treatment of this disease were I not again to caution him against an 
imperfect cure of it. Very often it becomes chronic, and renders the 
patient miserable for years. We should try to avoid this conse- 
quence. Too early a resumption of duties and active exercise should 
be especially prevented. When practicable, a continuation of treat- 
ment and avoidance of the causes which produced the inflammation 
are of equal importance. As a means of perfecting the cure which 
the more active treatment has brought about, the sedative effect of 
water affords us valuable aid. The sitz-bath and vaginal injections 
are the modes of using it. The sitz-bath ought to be used as much 
as the time and patience of the patient can be made to allow. An 
hour is short enough time, and two hours is better, twice or thrice in 
twenty-four hours. The injections should be copious, and may be 
used in the bath and of the same water. From two to four gallons 
of water ought to be passed through the vagina in this way each time 
the bath is used, by means of the perpetual rubber syringe. 

Acute Inflammation of the Mucous Membrane of the Uterus. — I do 
not know that I have ever met with an uncomplicated case of acute 
inflammation of the mucous membrane of the uterus. Cases that I 
have seen have been connected with inflammation of the vagina, and 
have arisen as the effect of some poison directly applied to the mem- 
brane. Most of them were gonorrhoeal, but in some I have been 



192 ACUTE INFLAMMATION OF THE UNIMPREaNATED UTERUS. 

puzzled to determine whether the poison of this affection was the 
cause or not. Probably this poison gets into families, where and in 
ways it ought not, and thus deceives us. However this may be, I 
think one of the worst features of gonorrhoeal inflammation is the 
frequency with which it invades the mucous membrane of the uterus 
and the difficulty of completely eradicating it. It is very apt to lurk 
in the uterus after the acute symptoms are removed and the inflam- 
mation gone entirely from the vagina, and thus require treatment as 
chronic endometritis. 

If I am not deceived by my observation, acute endometritis, of a 
non-specific character, is a very rare affection ; and as I have not seen 
it, and doubt its existence, I do not feel justified in compiling a 
description of it. 



CHAPTER XII. 

GENERAL CONSIDER ITIOXS ON "UTERINE DISEASE" OR 
HYSTEROPATHY. 

There is a long list of symptoms, called nervous, or sympathetic, 
which, although not exclusively confined to women, are more fre- 
quently found to manifest themselves in them. They were formerly 
regarded either as independent affections, or as having various sources 
of origin ; and although hysterical was the term usually applied to 
them, it was not definitely known in what manner they originated. 
Patient investigation has given us more definite and correct notions 
of them, and we have come to regard them as nearly always depen- 
dent on trouble of some kind in the sexual system. Medical men, 
however, are not united in the opinion that the symptoms alluded to 
are thus caused, but are divided into two well-defined parties with 
respect to uterine pathology. 

1st. There are those who believe that the uterus has very little 
sympathetic influence on the system ; that the diseases of that organ 
are more frequently the result of diseases in other organs than of 
independent origin ; that the symptoms accompanying and almost 
always found in connection with actual lesion of the uterus do not 
at all depend upon this organ ; that these symptoms may be cured 
without any attention to the condition of the uterus, and, in fact, 
whatever cures them, almost always cures the affections of that organ. 

2d. The other party holds the opinion that the sexual system of 
the female, in a state of disease, exercises a very morbid influence 
over nearly the whole organization ; that this morbid influence is 
particularly exerted over the spinal and cerebral nervous systems ; 
and that the only sure and permanent relief is found in the cure of 
the disordered condition of the uterus. 

Those who adhere to the latter view may be classified under two 
subdivisions, one of which holds that the sympathetic influence of 
the uterus is only manifested when that organ is inflamed or ulcer- 
ated, and that the cure of the inflammation and ulceration relieves 
the symptoms. The other maintains that inflammation and ulcera- 
tion are only of slight, if indeed of any, importance ; while the cause 
of all the difficulty is some sort of displacement. 

13 



194 ''UTERINE disease'" OR H YST ER P A T HT. 

It will probably surprise the student when he is told that all of these 
diverse and various opinions are held bv gynieeologists of equal emi- 
nence, inresrrlty. and opportunity for observation. There is reason 
for surpri-e in this consideration, and yet this same diversity of opinion 
exists in all departments of medicine ; for example, as to the nature 
and treatment of inflammatioD, as to the essential nature of typhoid 
fever and its treatment, as to the local or general origin of cancer, and 
the propriety of extirpation. How can this discrepancy be accounted 
for? It is not my purpose to answer this question at length, but 
merely to indicate a few obvious considerations, of which one is that 
the attention of medical men has been too recently directed with suf- 
ficient intensity to the points involved to enable them to make an 
induction full enough to convince by its results all the members of 
the profession of the correctness of any one view. This, therefore, is 
just the time when we meet with conservatism in the views of tem- 
perate and judicious investigators, as well as wdth the less laudable 
conservatism of those who have lived too long to improve. Another 
consideration is, that while judicious practitioners hold antag^onistic 
opinions as to the nature of diseases, they pursue so nearly the same 
line of practice as to lead to similar results in the treatment of them. 
A third consideration relates to the power of prejudice, which forms 
in very many minds an invincible barrier against the acquisition of 
truth : and the opinions imbibed in early education are those which 
are maintained the most persistently, sometimes in consequence of an 
unwillingness to learn, and sometimes even against the light of reason 
itself. From the pernicious influences of association and prejudice 
neither learned nor unlearned are exempt. 

Those who deny to the uterus much sympathetic importance in a 
state of disease are compelle<d to acknowledge it under states of in- 
creased vital energies. I think it is inconsistent to express a doubt 
of the sympathetic influence of an organ in a state of disease, while 
we admit that the same organ, when laboring under unusual vital 
excitement, causes an exaltation, depression, or depravation of func- 
tion in many important organs in the system. The stomach, when 
laboring under the stimulus of digestion, influences to a great degree 
some of the important organs of the Ixidy. The brain is alwavs more 
or less influenced by digestion ; when the stomach is strongly engaged, 
the brain is overwhelmed, and sleep is unavoidable. This is well 
exemplified in the torpidity of the serpent ; when gorged he is help- 
less. When the brain is profoundly engaged, digestion is imperfect 
and sometimes whollv arrestetl. In a state of disease there is also a 



twizim~ ' 



"uterine disease"' or hysteropathy. 195 

close sympathy between these two organs. AVhen digestion is taking 
place, the secretions of the kidneys differ from their state at other 
times ; and this is not so attributable to the change in the composi- 
tion of the blood (for this difference occurs too early to be due to 
such a cause) as to the influence of digestion on the innervation of 
those organs. There is very close sympathy between the kidneys 
and the stomach in a state of suffering. I cannot remember a case 
in which two organs sympathizing in their healthy functions do not 
more obviously effect each other in a diseased condition. Why may 
we not, therefore, reasonably infer this to be the case with the uterus 
and other organs ? It is interesting to notice some of the physio- 
logical and pathological effects evidently caused by the changes going 
on in the o;enital svstem of both male and female. All phvsioloo^ists 
agree that without a development of the genital organs, particularly 
the testes and the ovaria, there is permanent nullity in the character- 
istics of the individual. When the menses make their appearance 
they bring with them a long list of physical and functional changes, 
and at each periodical recurrence there is more or less nervous and 
functional derangement. Disease results when this process is arrested. 
Greater effects are produced by pregnancy. A case reported by Dr. 
Tyler Smith, in the Transactions of the Obstetrical Society of London, 
for 1859, exhibits uterine sympathies in a strong light. Dr. Smith 
savs : 

" In the early part of September (a little over two months from the 
probable time of conception), after she had been six weeks in the hos- 
pital, I was asked to examine her, the probability of pregnancy having 
suggested itself. She was at this time in a state of extreme emaciation ; 
the vomiting was constant ; the pulse ranged from 120 to 140 ; there 
was great tenderness of the epigastrium, and delirium occasionally su- 
pervened. At other times her state was one of serai-consciousness. She 
lay helplessly in the supine position, unable to move her body and 
limbs, from profound debility. I ascertained that the catameuia had 
last appeared about a fortnight before she came to the hospital (18th of 
July). She confessed, after much denial, to intercourse on two occasions 
shortly after this menstruation. The sickness came on suddenly and 
had continued without intermission. The uterus was found, on a digital 
examination, to be enlarged and the os uteri softened. The areola were 
rose-colored and the follicles somewhat developed, and the mammae were 
full and rounded, the development of the breasts contrasting in a re- 
markable manner with the atrophied condition of the body generally. 
These facts rendered the existence of pregnancy so extremely probable, 



196 "uterine disease" or hysteropathy. 

that she was subsequently placed under my care and removed to the 
Boynton ward." 

On a regimen consisting of one teaspoonful of beef tea alternated 
with the same quantity of milk the vomiting ceased ; a gradual in- 
crease of these articles improved the condition of the patient until the 
3d of December, when she aborted. She did well for two or three 
weeks after the abortion, when symptoms of acute phthisis appeared, 
and she left the hospital in February, 1860, in an advanced stage of 
consumption. When in her lowest condition, soon after putting her 
on the beef tea and milk, Dr. Smith describes her as follows : 

" The pulse continued high, and other symptoms of exhaustion re- 
mained without abatement. For many days it was impossible to deter- 
mine whether she was in that state of pause from vomiting produced by 
exhaustion, which has sometimes been found to precede death in such 
cases, or whether the stomach was slowly regaining its tone. Bedsores 
appeared on the hips and nates ; the process of emaciation continued, 
and on the 16th of September her weight was on\j forty-seven and a half 
pounds. ... I am not aw^are of any instance on record of such a light 
weight. Before the commencement of her illness, she is represented to 
have been plump and in good condition." 

Dr. Smith adds : 

" In some of the worst and most dangerous cases of vomiting from 
irritation of the gravid uterus, the peril occurs at such an early period 
that pregnancy may not be suspected, and if the suspicion be entertained 
it is difficult to diagnose it with certainty. I believe that many fatal 
cases occur from this cause in hospital and private practice without their 
real nature being suspected. There is nothing in the whole range of 
physiology or pathology more extraordinary than the fact that the 
gravid uterus, without itself being the seat of special pain, irritation, or 
disease, should excite fatal disease by reflex irritation in some distant 
organ. In this way pregnant women may be destroyed by secondary 
disease of the brain, heart, lungs, kidneys, stomach, or intestines. In 
fact, there is in particular cases no limit to the poisonous influence 
exerted on the rest of the economy by the gravid uterus." 

He would be an obstinate skeptic in pathology who, having once 
observed such a case or having read the above graphic sketch of it, 
should ignore the uterus in his pathological estimation. Can it be 
possible that an organ so potent in evil work upon other organs under 
a state of physiological hyperexcitement, does not exert any bad in- 



"uterine disease" or hysteropathy. 197 

fluence in inflammatory hyperexcitement ? I think there is no 
doubt that it does do so; and I affirm, after an observation of a large 
number of unmistakable cases, that the unimpregnated diseased uterus 
does produce grave and even fatal disorders in other parts of the or- 
ganism by its reflex or sympathetic influence, while the organ itself is 
not suspected to be the original cause of the widespread disorder. 
This is also the testimony of others who have made these diseases a 
special study. 

It is curious and instructive to notice the similarity of symptoms 
excited by a diseased uterus and those arising from spermatorrhoea ; 
and I think that the opinion of the sympathetic connection between 
diseases of the uterus and other organs is much strengthened by the 
fact that, in the male, a slight inflammation or an irritation in the 
urethra excites much ruinous disorder in the system at large. This 
urethral inflammation, like uterine, does not often lead to fatal dam- 
age. It may be said that very extensive urethritis does not generally 
produce this effect ; even chronic gleet does not produce it. But then 
chronic gleet affects a different part of the urethra. May there not, 
therefore, be very similar pathological relations between the portions 
of the orenital canal affected in the two instances and the o-eneral svs- 
tem in the two sexes? Or will it be said that this kind of urethritis 
arises from general conditions? I think, considering the well-known 
and acknowledged causes of s})ermatorrhoea, such an assertion will 
not be made. The similarity of the two cases affords an argument in 
favor of the efficacy of local causes in producing uterine inflamma- 
tions, and of the }X)werful and general sympathetic influence of them 
when once originated. 

In order that the similarity may be the more apparent, I subjoin 
an abstract of some of the most common sympathetic influences of 
the two, and place them in juxtaposition for convenience of com- 
parison ; 

Uterine Disease. • Spermatorrhfea. 

Sterility. Infecundity, with or without impo- 

tence. 
Absence of sexual desires. 

Absence of fever. Absence of fever. 

Indigestion. Indigestion. 

Intestinal flatus, cramps, and pains. Intestinal flatus, cramps, and pains. 

Sometimes emaciation. Sallowness. Emaciation, with salloAvness and lead- 

A healthy appearance preserved in en color about the eyes. Patients some- 
some cases under severe sufiering. times preserve a perfectly healthy ap- 

pearance. 
Great languor of capillary circulation. Coldness of hands and feet. 



19S 



UTERINE DISEASE OR HYSTEROPATH Y. 



Uterine 

Embarrassment in the respiratory 
movement. 

Apprehension of disease of the heart 
from palpitation and other irregularities. 

Debility of muscles, and inability to 
walk. 

Nervous spasms. 

Pains in the loins and legs in the course 
of the nerves. 

Sight often bad, and other senses em- 
barrassed. 

Vigilance. 

Cephalalgia. 

Irritability in place of amiability. 

Despondency. 

Failure of memory. Weakening of 
the mind. 

Mania. 

Scarcely any tendency to spontaneous 
recovery. 



Spermatorrhosa. 

Kespiration often very much embar- 
rassed. 

Palpitation of the heart, and other 
alarming derangements of its action. 

Great weakness of muscles, sometimes 
almost paralysis. 

Spasms of epileptic character. 

Pain in the loins and limbs ; nervous 
shocks of pain. 

Senses often seriously affected, partic- 
ularly the eyes. 

Vigilance. 

Cephalalgia. 

Congestion of the brain. 

Change of character on account of 
mental disturbance. 

Hypochondriasis. 

Loss of memory ; impairment of the 
intellect. 

Insanity. 

Scarcely any tendency to spontaneous 



The above comparison of symptoms between spermatorrhoea and 
uterine disease is not intended to be complete, but merely to call at- 
tention more pointedly to their similarity. The more we study themy 
the more apparent is the similarity in the general eifects of these dis- 
eases upon the system. I have elsewhere intimated that the disease 
in the two cases is inflammation of a macous membrane and increase 
in the secretion of it^ to which in the case of spermatorrhoea is added 
the product of a gland, namely, the testes. 

Another and the most important proof of the general influence of 
these local affections is the subsidence of the general symptoms after 
the local disease is cured. It is said by those who deny the local 
origin of nervous symptoms in the female that the general treatment 
is such as to insure a cure of the local disease in spite of local 
irritants. All judicious writers very properly direct the use of gen- 
eral treatment, yet it is not in many cases essential to a cure ; in such 
it is merely auxiliary. This may be readily verified by anybody who 
will observe the effects of both kinds of treatment. I cannot resist 
the conviction, after a careful perusal of what I have seen written 
against the local origin and treatment of uterine diseases, that the 
experiments of the writers were not made with sufficient thorough- 
ness; and I think that some of them have allowed themselves to be 
content with imperfect trials in consequence of preconceived opinions. 



199 

A judgment is only valuable which has been founded on thorough 
treatment; and as it requires very considerable experience, and a 
correct knowledge of the anatomical, physiological, and pathological 
appearances of the mouth and cervix uteri, I am convinced that 
errors arise unknowingly by misinterpreting what is seen ; that, in 
other words, we do not always know when the pathological has 
entirely given place to the physiological and proper anatomical ap- 
pearances. I have been often asked by medical men, why it is, that 
after a women has improved to a certain point under the influence of 
local treatment, giving promise of a satisfactory cure, all progress 
ceases, and the cure remains imperfect. In many instances I have had 
an opportunity of examining the cases in question, and have found 
that there was still sufficient disease to account for the state of the case, 
and that further local treatment removed the impediment to a cure 
and perfected it. 

It would be contrary to all other instances in which general or 
secondary affections arise from sympathetic influence, if some of the 
secondary affections did not outlast the primary disease. Accordingly 
we find that in some cases of long-standing uterine disease the organs 
affected by it become permanently diseased, and after the cause is 
removed require independent treatment for their relief. No proper 
objection can be urged against the theory in consequence of this fact, 
as it is only in accordance with other examples, as has been already 
stated. The cases in which the general symptoms do not subside, 
however, after the cure of the local (when the former are the conse- 
quence of the latter), are not very frequent exceptions to the general 
rule, that to remove the cause is to cure the disease. And when the 
general symptoms are not cured, the condition of the patient is gen- 
erally, if not invariably, improved by the removal of some and the. 
amelioration of other symptoms. 



CHAPTER XIII. 

SYMPATHETIC SYMPTOMS OF UTEKINE DISEASE. 

I SHOULD not deem it necessary to go into a detail of the particular 
sympathetic accompaniments of diseases of the uterus, were I not 
convinced that they are often considered independent affections, and 
their origin not suspected by very many practitioners ; and that an 
immense amount of suffering is now borne as a necessity by women, 
that might be relieved, if we would investigate and study their ailments 
with as much patience as, and with no more reserve than, we approach 
and investigate lung diseases or throat affections. 

Dr. Scanzoni * says : '^ The sympathetic phenomena which very 
distant organs so often present during the course of uterine diseases 
are of the highest scientific importance." They are the more impor- 
tant, because our attention is more frequently called to them than to 
their original exciting cause. The secondary or sympathetic diseases 
often distress patients most, and the fact of their mentioning no other 
troubles may, without inquiry, mislead us into the opinion that they 
are independent affections. 

The general symptoms attendant upon uterine disease are primarily 
sympathetic and secondarily neurasthenic. The sympathetic are reflex. 
An impression is produced on the ganglia of that portion of the 
sympathethic pervous system connected with the uterus and ovaries 
especially. Thus propagated it is conveyed along the nerve fibrill^ 
to the genito-spinal centre, and from this reflected to all the organs 
with which the genital system is in sympathetic relation. 

The stomach is deranged in various ways ; the bowels, the liver, 
and the spinal and cerebral nerve centres become affected. The de- 
rangements of digestion interfere with nutrition, the blood becomes 
poor in the materials calculated to sustain the vigor of the nerve 
centres ; they become anaemic, and in this way nervous exhaustion 
occurs, and we have with the original sympathetic symptoms, or suc- 
ceeding them, neurasthenia. 

Neurological writers, among whom are Drs. Weir Mitchell, Beard, 
and Professor Jewell, ascribe neurasthenia 1o an exhausted state of the 
nerve centres. If I rightly understand what they mean by this it is 

* Diseases of Females. 



SYMPATHY OF THE STOMACH. 201 

that the brain and spinal cord have become damaged by overaction. 
I do not mean by damage, structural lesion, but a condition in which 
the cell action is slow, labored, and painful, because the parts have 
been overworked, and according to this method of interpreting the 
symptoms they prescribe rest as one of the essential parts of the cure. 
This is so different from the way I look at the subject that I will risk 
a concise statement of my views. 

I think that the nerve centres do not become exhausted, but that 
the blood circulating through them does become exhausted of the 
material necessary to promptly renew the loss during functional action 
of the nerve centres. On account of the want of general vigor, the 
heart and arteries may not transmit the blood through them in the 
usual quantity, but if the circulation is not deficient in quantity, 
the blood itself is deficient in quality. AVith a deficient supply of 
nutritive material their functions are performed irregularly and im- 
perfectly, and there is neurasthenia. 

If my explanation of the origin of neurasthenia is correct, absolute 
rest is not so important to the cure as full feeding. 

We shall be able to study the general symptoms of uterine disease 
more profitably by taking them up separately as they are manifested 
by different organs, and without attempting absolute correctness in 
this respect, it will be practicable to present them in something like 
the order of frequency in which they occur. 

Sympathy of the Stomach. 

The stomach is apt to be disturbed as early and as frequently as 
any other organ by uterine disease. This is no more than we would 
expect, considering how often and intensely it is influenced by preg- 
nancy, and its great readiness to complication in most affections of 
other parts of the system. Si mple anorexia is one of the most common 
of the sympathies of the stomach, as is also its contrary, voracity ; but 
occasional unbecoming, and even disgusting, depravity of appetite 
is also not uncommon. Inappetency sometimes proceeds to the ex- 
tent of loathing of food and to longing for inappropriate articles of 
diet. Nausea, with loathing of food and disgust at the smell of it, 
is another feature of stomach trouble ; also frequent vomiting when 
the stomach is full ; an absence of discomfort when it is empty, and 
the vomiting is sometimes worse when there are no ingesta, and 
nothing is expelled but some of its secretions, which are usually acid, 
but sometimes bilious. Gastralgia may occur when the stomach is 
empty; or during digestion, or immediately after swallowing food. 



202 SYMPATHETIC SYMPTOMS OF UTERINE DISEASE. 

The capacity of the stomach to digest food of any kind is often im- 
paired, but more frequently some particular sort of food disagrees 
with the stomach and embarrasses digestion ; in short, almost every 
form of disordered stomach may be looked for as the result of the 
sympathetic influence of diseases of the uterus upon that organ. The 
grade of functional disturbance may vary from the slightest incon- 
venience to that complete arrest of digestion which rapidly induces 
inanition and death. Extreme cases of indigestion, however, are 
not of frequent occurrence, and the disturbances are rather those of 
great annoyance than such as result in very serious impairment of 
nutrition ; and many patients who constantly complain of suffering 
very severely from sensitiveness connected with digestion attain to a 
state of apparent robust embonpoint. 

Sympathetic Disease of the Bowels. 

The bowels probably sympathize in diseases of the uterus next in 
frequency to the stomach, and their functional derangements are 
multitudinous. Constipation is very common. The bowels, in many 
instances, have apparently no natural tendency to move. I have one 
patient who assures me that she has often been fourteen days without 
any fecal discharge whatever, and that she dare not try how long she 
could go without it, but says that she always uses some means to pro- 
mote the alvine evacuations. In other cases constipation terminates 
with diarrhoea, and an alternation of diarrhoea and costiveness, which 
lasts from two to six days, is a constant and habitual state with the 
patient. In cases of constipation resulting from this cause, the con- 
stipation seems to depend upon a want of muscular tone in the intes- 
tines; peristaltic action is deficient, and the appearance of the evacu- 
ations is in all repects natural, and their consistence proper. In other 
cases the secretions are deficient, and the stools are dry, hard, and 
small in quantity. But constant diarrhoea and irritable bowels are 
also frequent accompaniments of uterine disease. The passages may 
be profuse, watery, and exhausting, or profuse and fecal. A peculiar 
kind of discharge in cases of diarrhoea in uterine disease presents a 
rauco-fibrinous cast of the intestines. The casts are sometimes quite 
tenacious and of variable length, from two to ten inches, and are often 
complete casts of the intestinal tube; at other times there are shreds 
of false membrane of irregular shape and size. The discharge of 
these substances is usually attended with some dysenteric symptoms. 
The diarrhoea sometimes seems to be excited or aggravated by certain 
articles of food; at other times one kind of ingesta seems to agree as 



SYMPATHETIC AFFECTIONS OF THE NERVOUS SYSTEM. 1203 

well as another; and, again, the bowels may be quite regular, except 
at or near the period of menstruation. The irregularity is often en- 
tirely confined to that time. With or without diarrhoea there may 
be tumultuous gaseous commotion in the bowels; they may be more 
or less distended, or without distension there may be annoying borbo- 
rygmus and motion, from the gas passing from one part of the intes- 
tines to another, inducing the opinion that pregnancy exists. The 
gaseous distension of the abdomen is sometimes so extensive and per- 
manent as to induce the overwilling patient to believe that it is caused 
by gestation, and being frequently connected with hysterical crafti- 
ness, she may impose the same belief on a careless practitioner. 

Sympathetic Affection of the Liver. 

Closely connected with and, of course, very much influencing the 
condition of the alimentary canal, is the condition of the liver. 
Sometimes the bile is poured out in such copious quantities as to 
induce full and free discharges of it from the stomach by vomiting, 
and to stimulate the intestines to copious bilious diarrhcea when they 
are not irritable, but subject to the ordinary stimulation of ingesta. 
This overflow of bile comes in paroxysms, and produces a sort of 
cholera morbus. When it occurs only once a month, it is apt to be 
near the time of menstruation, or it may return several times between 
the monthly periods. But there is often a persistent absence of secre- 
tion for a time, or this condition may alternate with the other; or 
the bile, instead of finding its way into the alimentary canal, may 
pass into the circulation and give the skin a jaundiced hue. When 
the functions of the liver are seriously disturbed, there is apt to be 
at one time a deficiency of bile, and at another a great redundancy. 
I have not seen this oro^an cono^ested to anv o-reat extent, as observed 
by Dr. Bennett. But I have seen an enlargement of the spleen in 
such instances, though I have not supposed it to be the result of the 
influence of uterine disease. When copious effusions of bile take 
place somewhat suddenly, all the pain and spasmodic action observed 
in bilious colic are likely to present themselves. 

Sympathetic Affections of the Xervous System. 

Much more distressing if not more serious suffering is experienced 
in the nervous system than in the digestive apparatus. Aches, pains, 
and complaints of evident nervous ailments are the peculiar province 
of uterine disease. There is hardlv a disao:reeable or even excruci- 
ating sensation that these patients do not experience; and too often 



204 SYxMPATHETIC SYMPTOMS OF UTERINE DISEASE. 

this real suffering is mistaken by the friends for imaginary, and the 
patient's complaints are treated with unreasonable impatience and 
rudeness by persons from whom she ought to receive kindness and 
sympathy, because her appearance does not correspond with her mor- 
bid sensations, as we are apt to observe them in other examples of 
disease. It is remarkable, too, and a fact that often impeaches them 
with insincerity in their complaints, — when the uninitiated are the 
judges, — that these patients will pass from a state of excruciating 
suffering and loud complaints, under a little excitement, to one of 
actual enjoyment and hilarity, or conversely. The transition from 
the excitement of private company, or a public party, gives way in 
a few minutes to a doleful condition of suffering and unappeasable 
complaints. The inconsistency of the complaints and enjoyments, 
the incapacities and the performances of these patients, are almost 
characteristic, — at least in their sudden alternation, — and are inex- 
plicable in any other way than by supposing that the pains in the 
different organs, to which they are referred, are more dependent upon 
the general nervous susceptibility than upon the organic disease of 
even trivial character. They are strictly neuralgic in their nature, 
and confined to the nerve-matter or tissue of the parts. A great 
number of the disagreeable sensations and pains appear more fre- 
quently in particular parts, and hence may be distinctly referred to 
in this description. 

Accompanying Manifestations of Moral and Intellectual Perverseness, 

During the spasmodic action which, in the majority of cases, has 
to a critical observer the appearance of being partly voluntary, there 
is apt to be a singular perverseness of moral and intellectual mani- 
festations, which was on a certain occasion very graphically expressed 
by a clerical friend in speaking of a patient, by saying that she 
"seemed to be actuated by an evil spirit.'' In the midst of great 
suffering, patients not unfrequently try to bite and otherwise wound 
those who endeavor to restrain their violent agitation ; they attempt 
to throw the covering from them Avith the apparent object of expos- 
ing their person, or say some very perverse things. At other times 
they attempt to imitate the symptoms of some grave organic affection. 
One patient, by heaving up the lower part of the chest spasmodically 
at rapidly succeeding intervals, induced her friends to think that she 
had violent palpitations of the heart, and therefore must be the sub- 
ject of cardiac disease; she also imitated throbbing of the temples by 
spasmodic contractions of the temporal muscle. When this throbbing 



SYNCOPAL CONVULSIONS. 205 

of the temples was very violent, I requested her to hold her mouth 
open so as to relax those fibres, but she looked up and said very 
wicked things, and became contemptuously calm. A request to hold 
her breath when the palpitations were violent, induced her to act in 
the same way, and caused an instantaneous cessation of them. The 
great peculiarity in these spasms has always seemed to me to be a 
guarded cunning, a deceitful and perverted consciousness. To a close 
observer this is always easily detected. By using the foregoing epi- 
thets descriptive of the peculiarity of this kind of hysterical phenom- 
ena, I do not wish to be understood as saying that deceit, cunning, 
etc., are indications of freedom from disease on the part of patients 
^^ho are thus affected. I think this is not usually the case, but that 
they are the result of the morbid state of the mind and body. The 
spasmodic action of the muscles is not contemporaneous in the corre- 
sponding extremities, as in epileptiform hysteria or epilepsy, but is 
so irregular as to move the body in many different directions instead 
of giving to it frequently repeated similar motions. 

Syn copa I Con vulsio ns — Hystero-Ep ilepsy. 

There is a singular variety of semi-convulsions, or syncopal con- 
vulsions, which I have noticed in a few cases, that I do not remember 
to have observed in any other connection. They occur very frequently 
after they have once seized the patient, as often as three or even six 
or eight times during the twenty-four hours. They take place in 
the daytime or at night, during the sleeping or waking condition, and 
do not seem to result from any particular excitement at the time. If 
the patient is sitting and talking, or is engaged in work, she suddenly 
ceases and slowly sinks down to the floor; she turns her head to one 
side, almost ceases to breathe, becomes pale and trembles, sometimes 
very gently, sometimes violently. This state lasts only for a few 
seconds ; she arouses, looks about confusedly, and although she knows 
she has had a fit, as her friends call it, she does not remember dis- 
tinctly anything which passed during the time. As these attacks 
become chronic, they may be attended with very slight convulsive 
movements, frothing at the mouth, and sequential somnolence; but, 
ordinarily, this is not the case. If the patient is attacked in the night 
while asleep, unless some person observes the attack, it will not be 
known to have occurred, the patient being unconscious of it. There 
is generally, however, movement enough to awaken anybody who 
may be in the same bed with the patient. In all cases of this kind 
I have noticed great impairment of memory, particularly of recent 



206 SYMPATHETIC SYMPTOMS OF UTERINE DISEASE. 

circumstances. There is not usually any severe pain in the head or 
spinal centres; there is, in fact, no prominent painful circumstance 
apparently connected with the case. Patients having such paroxysms 
are generally worse at or near the time of menstruating; but some- 
times they are quite exempt from them at this time, but have them 
not long after the menstrual congestion is over. 

* Moral and Mental Derangement. 

No more constant derangements, perhaps, occur than are observed 
in the mental and moral qualities of the j^atient. The patient loses 
the complete control which she has been in the habit of exercising 
over her emotions, and finds herself becoming despondent, fretful, 
suspicious, and unsteady in her purpose; whimsical, having desires 
not before experienced, indulging in thoughts and feelings toward 
her friends which in her former days she did not entertain. She will 
often call herself a changed woman. If the source of irritation is 
not discovered and removed, she loses her strength of will entirely; 
and, instead of her moral feelings being guided by her will under the 
influence of a sound judgment, she exhibits indecision, and wavers 
in matters about which she heretofore had no difficulty in making 
decisions. She finds herself giving way to peevishness to a frightful 
degree ; nobody can please her. In place of her usual satisfaction in 
the attention of her friends, she finds fault with their efforts to make 
her comfortable. Sourness, moroseness, jealousy, carelessness, timid- 
ity, and peculiar perverseness change her nature entirely. Sometimes 
one class of ideas will seize her whole faculties, and she will scarcely 
think or talk of anything else. She has no patience with anybody 
who will not listen to her, and believes everybody to be her enemy 
who cannot sympathize with her in her imaginary troubles. The 
different phases of mental and moral troubles under which the patient 
labors are almost innumerable. As will be seen, this state of things 
closely borders on insanity, and there is no doubt that insanity is 
often the result of uterine irritation in patients who are hereditarily 
predisposed to it. I think I have seen cases of insanity that were 
excited into activity by the great nervous irritation connected with 
uterine disease. But in place of this steady deviation from her nat- 
ural mental condition, the patient may generally be sane, and show 
an abnormal state of mind only when circumstances occur which are 
likely to excite her, when she loses all control and indulges in exces- 
sive anger. Sometimes, in a fit of despondency or melancholy, she 
contemplates or even attempts suicide. Or, if her sense of wrongs 



CEPHALALGIA. 207 

weighs heavily upon her, and no means of redress shows itself, she 
thinks seriously of fleeing from what she fancies is the cause of them. 
Srill another sort of paroxysm exhibits acts of a depraved and inde- 
cent nature, so disgusting as to shock the witnesses of them, and in 
her recollection of them to mortifv her exceedingly. The common 
hysterical paroxysm of crying without a sufficient cause, the indul- 
gence in unbecoming and unseemly levity, rapid alternations of de- 
spondency and hope, need hardly be mentioned, from their familiaritv 
to every observer. "When, in reference to such unbecoming exhibi- 
tions, patients are kindly remonstrated with, they will, in general, 
acknowledge the impropriety of them, but will end with saving, "I 
tannot help it,*' which is the unanswerable and, doubtless, truthful 
exposition of their mental condition. Xeglect of duty in all the rela- 
tions of life is one of the phases of their mental state. Sometimes a 
wilful selfishness, caring for nothing but what they fancy will make 
them happy or conduce in some way to their interests, absorbs their 
whole mind and governs all their actions. At times there is an in- 
telligent appreciation of the impropriety of their actions. 

Cephalalgia. 

Cephalalgia, in some form, either partial or general, is a very com- 
mon attendant upon the nervous susceptibility of uterine patients. 
It is often general; the whole head seems to pulsate and thrill with 
terrible pain, rendering the patient almost frantic with the intolerable 
aching. In a few hours it subsides, leaving the nervous energies 
prostrate for a short time, but otherwise the patient is free from all 
pain. This subsidence would not be complete if the cephalalgia were 
anything but nervous pain in the head. The general cephalalgia is 
often, but not necessarily, attended by nausea and vomiting, or other 
stomachic, hepatic, or intestinal disorders, and may be relieved, when 
that is the case, by emesis or an alterative cathartic. This is what is 
commonly called sick headache. The most frequent forms of pain 
in the head, however, are partial, and confined to some particular 
part; as hemicrania, confined to the whole of one side, or a lanci- 
nating pain in the temple, brow, or eye. All these are very common 
pains in uterine disease; but persistent or frequently recurring pain 
in the occipital region, or on the summit of the head, Ls nearly pathog- 
nomonic of uterine disease. It is almost invariably the case that a 
woman has chronic uterine disease if she complain of persistent pain in 
either of these regions. The occipital pain I have observed in this 
connection much oftener than the pain on the top of the head. It is, 



208 SYMPATHETIC SYMPTOMS OF UTERINE DISEASE. 

ordinarily, a dull aching, that completely unnerves the patient and 
renders her unfit for her duties for days together; it is usually very 
persistent, in some patients being almost constantly present, but in 
other cases only occurring once a month, ordinarily at the menstrual 
period. The pain on the top of the head is described generally as a 
burning pain; patients complain that they have all the time a hot 
place on the top of their heads. This pain is probably more constant 
iu patients that have it than any other about the head. I have ob- 
served that when patients suffer greatly froui pain in the head, they 
complain less of suffering which is more directly referable to the 
uterus than when any other symptom seems to predominate. Indeed, 
I have met with patients who were martyrs to these excruciating head- 
aches who did not complain of anything which pointed directly to 
the uterus as the origin of their sufferings, and yet upon examination 
that organ was found ulcerated and inflamed ; and when these con- 
ditions were cured by appropriate treatment, the headache ceased to 
annoy them. A remarkable instance of this kind occurred to me 
several years ago. The patient came to town to consult me about 
what she called neuralgia. The pain was located in the occiput ; it 
lasted one week in every four (her menstrual week), and when very 
severe she had hysterical convulsions. This took place at almost 
every recurrence of the headache. She had no backache at any time; 
her menses were natural in every respect, as far as I could gather 
from her history, on which I placed the more reliance from, the gen- 
eral intelligence of the patient. She could walk long distances with- 
out inconvenience, had no pains in the hips, groins, or le^s ; in short, 
she made no complaint from which I could infer the origin of the 
nervous suffering to be in the uterus, except that the headache was 
sure to come on at the time of menstruation. Her uterus was ulcer- 
ated and inflamed, and after appropriate treatment was cured, when 
the sufferings vanished, and she has since enjoyed complete immunity 
from them. This woman was about thirty years old and in the midst 
of her childbearing period, and it might hence be supposed that the 
uterus would exercise more sympathy than at any other tiuie of life; 

but, as the following case will show, this is not the fact: Mrs. , 

forty-nine years of age, had ceased to menstruate three years before 
I saw her, but was subject to the most excruciating headache every 
six or seven days, each attack so prostrating her that she would 
scarcely recover from one before the next would appear. She had 
some backache and inconvenience in walking, but these symptoms 
scarcely attracted her attention amid the terrible sufferings caused by 



HYPER-ESTDESIA. 209 

her headaches. Six montlis' treatment addressed to the uterus alone 
sufficed to remove all this great trouble and render the woman com- 
fortable and capable of her duties in life. The overwhelming influ- 
ence of this terrible cephalalgia on the nervous system seems to occupy 
so completely the capacities of it that minor pain is unheeded, and 
no coo^nizance is taken of the suiferings of the lass sensitive but in- 
flamed and mischief-making uterus. 

Affections of the Spinal Cord. 

The spinal cord seems to partake very much of the sensitiveness 
of the nervous system^ probably more so than the brain. Pain in 
some portion of the spine is almost universally present in uterine 
disease, but is most common in the sacral and lumbar regions. Pain 
is so oreneral in those reo^ions that it has come to be resrarded as neces- 
sary, in the estimation of very many persons, to establish the probable 
existence of this affection. The pain is fixed and almost constant, 
but aggravated by anything that excites the uterine vascular system, 
as standing or walking for a long time, lifting or jumping, or sudden 
emotions. Fright, anxiety, or anger, as the patient says, "flies to 
the back'"' and aggravates the pain. It is especially apt to be worse 
durino^ the menstrual cono;estion. Sometimes walking^ so much in- 
creases it as to incapacitate the subject for that kind of exercise. An 
expression often made use of to signify sensitiveness of the back, is 
*^weak back.^' Women will say, "I have not exactly pain in my 
back, but it is so weak that I cannot move on account of it, or can 
hardly stand, or cannot arise from a stooping posture." The pain 
may be fixed in any part of the spine. I have a patient whose back- 
ache is at the junction of the dorsal and lumbar regions. In connec- 
tion with these pains there is often tenderness in the same region, so 
that pressure causes great complaint. Tlie pain is not only increased 
in the part pressed upon, but it sometimes darts along the nerves 
around the body. 

Hyjyercesthesia. 

Akin to pains in various parts is hyperesthesia without inflamma- 
tion ; great sensitiveness of particular parts. Tenderness of the scalp 
is often complained of. The whole surface of the head is so tender 
as to require great care in dressing it, and no pressure can be toler- 
ated without an effort. Of a similar nature is tenderness along the 
spine. The different spinous processes in some sections of the column 
cannot be touched without giving the patient great suffering. Pres- 

14 



210 SYMPATHETIC SYMPTOMS OF UTERINE DISEASE. 

sure upon these tender vertebrae sometimes causes pain to shoot along 
the spinal nerves, passing out of the intervertebral foramina in the 
neighborhood. There is occasionallv, also, general tenderness of the 

abdomen. 

Anrrstliesia . 

Much less frequently there is anaesthesia of some particular parts. 
The patient complains of a want of the ordinary sensitivene^s in 
them, or there is a feeling of numbness, which lasts for some days, 
and which recurs so often as to obtain the distinction of a symptom 
of the case. 

The muscular through the nervous system is, in many cases, very 
seriously affected. Cramps and spasmodic action are very frequent 
in particular cases, and they are confined almost constantly to certain 
limbs. They occur more frequently in the lower than in the upper 
extremities. 

Spasms. 

A worse state of things, however, exists when there are general 
spasms of the limbs and abdominal walls and hysterical convulsions. 
They are apparently induced by fatigue, or occur at the time of men- 
struation. The patient, after complaining of severe pain in the stom- 
ach, falls into a state of general convulsions, which lasts from thirty 
seconds to some hours, and subsequently sinks into a state of quietude, 
but not of insensibility. These attacks are usually repeated several 
times and then subside, leaving the patient in the possession of her 
usual physical condition, which is one of nervous misery. 

SympathetiG Pains in the Pelvic Pegion. 

Painful localities are generally found about the pelvis, in the in- 
guinal or internal iliac region exceedingly common. Immediately 
above one of the groins a constant and fixed aching may be found, 
which is aggravated by all the circumstances that increase the pain 
in the back. Most generally there is some tenderness or soreness in 
the part, which is increased by pressure. The pain sometimes ex- 
tends to the hip and side of the pelvis. It is much more frequent in 
the left side, but is often confined exclusively to the right, and less 
frequently it is in both sides alike. In more rare instances the pain 
is centrally situated behind the s^ymphysis pubis. 

Extension of Inflammation to the Bladder and Pedum. 

The patient will often say she has pain in the bladder, or pain in 
the rectum, and believes that these regions are affected. The two 



MUSCULAR WEAKNESS. 211 

last pains, when complained of, are generally very appropriately 
stated to be in the bladder and rectum, and are indicative, for the 
most part, of an extension of inflammation to these two organs. 
When this is the case, pain accompanies or rather is increased by 
micturition, or may occur immediately after it. The same remarks 
are applicable to the al vine discharge; during defecation the pain is 
increased, or then only occurs. These pains are not, strictly speak- 
ing, sympathetic, but occur as consequences of the extension of in- 
flammation, and indicate correctly its locality. In the iliac region 
it sometimes extends up the side as far as the mammary region, or 
there may be pain in this latter place not connected with the former. 
The pain may likewise be situated between these localities and be 
independent of any pain in them. 

Affections of the Sciatic and Anterior Crural Nerves. 

Pain in the course of the sciatic, obturator, or anterior crural nerves, 
is very common in uterine affections of an inflammatory nature. It 
is often so severe and aggravated by exertion as to incapacitate the 
patient for walking. Particular motions cause pain according to the 
nerve affected. When the sciatic is the seat of pain, sitting down, 
especially on a hard chair, increases it, so that the patient resorts to 
cushions for defence against pressure. Pain in the coarse of one or 
more of these nerves is often the most distressing circumstance con- 
nected with the case, and it is often treated as neuralgia seated in the 
nerves, while the cause is not even suspected. The pain may occupy 
the whole length of the nerve, or it may be confined to its upper or 
lower parts, or to an intermediate portion of variable length. The 
part of the limb traversed by the nerve may be tender or not; most 
frequently there is no tenderness. The pain may be fixed, or darting 
and transitory. It may be constant or paroxysmal; the patient may 
enjoy immunity for hours and days, or even weeks, or she may be a 
constant sufferer from them. They are apt, as other pains are, to be 
greater during menstrual congestion than at any other time. The 
pains emanating from the pelvis are not sympathetic, nor are they 
probably reflex ; but they are caused very likely by pressure of the 
uterus, or they may be produced by an extension of the inflammation 
to the nerve-sheaths. 

Muscular Weakness. 

Extreme muscular weakness — I do not mean that which results 
from general debility, but of some particular set of muscles — is often 



212 SYMPATHETIC SYMPTOMS OF UTERINE DISEASE. 

present as an accompaniment of uterine disease. This is most fre- 
quent in the back and lower extremities, not often in the upper ex- 
tremities. It Is probably imperfect innervation of the part, or it may 
be some affection of the muscles themselves. I have been inclined to 
look upon it as partial paralysis, resulting from reflex irritation. More 
or less numbness of the parts exists in connection with the weakness 
of the muscles. 

Circulatory System. 

The circulation and its organs are very often deranged to a dis- 
tressing degree. Palpitation of the heart is often troublesome, and 
patients are apt to think themselves the subjects of disease of the 
heart. We are often consulted solely with reference to this symp- 
tom, it having absorbed the attention and awakened the apprehension 
of the sufferer to such a degree that her other inconveniences were 
forgotten or overlooked. These palpitations are sometimes attended 
with pain in the region of the heart, which occasionally shoots up to 
the left shoulder and down the left arm to a greater or less distance, 
the distress being so great as to amount almost to angina. The pal- 
pitation Is worse during nervous excitement. It occurs generally in 
paroxysms. We meet with instances in wdiich it oftener occurs after 
lying down at night than at any other time. Sometimes it seems to 
be increased during digestion. The sensation of palpitation does not 
seem to be at all commensurate with the increased excitement of that 
organ, and vice versa. I have observed instances in which the patient 
complained of violent palpitation, while the pulse and heart, as far 
as I could judge, were not at all disturbed. In such cases we might 
say that the sensitiveness of the heart was increased until Its ordinary 
motions were perceived by the patient. Indeed, the pains and in- 
creased irritability of the organs supplied with the great sympathetic 
nerve seem to result from increased susceptibility or sensitiveness 
instead of oro^anic chanones. There is also sometimes a sensation of 
throbbing, as though the blood was passing through the arteries in 
increased quantities, and with increased force in some parts of the 
system; this occurs mostly about the head, sometimes in the hands 
and feet, and occasionally inside the head, apparently in the brain; 
also about the genital organs. Great irregularity of distribution of 
the blood Is often observable, the hands and feet being uncomfortably 
cold, and continuing in that state for twenty-four hours at a time. 
In connection with cold extremities, the head is apt to be hot, or 
w^armer than natural ; this heat of the head may also be present when 



RESPIRATION. 213 

the feet and hands are of the common temperature. The heat about 
the head and face is sometimes almost constantly present in certain 
patients, and is the source of great annoyance to them. It is apt to 
be caused by anything that excites the person. The heat is greatest 
and frequently exclusively located on the top of the head. I do not 
think that this sensation of heat arises from any other cause as fre- 
quently as from uterine disease, and I am sure it is one of the most 
common symptoms in such disease. There is great heat complained 
of in the back of the head also, in many instances, and sometimes it 
extends along the spine, affecting the whole or only sections of it. 
Burning in the sacrum and loins is very common. Flashes of heat 
and flushes of color in the face and head, and even in other parts of 
the body, are very common and annoying occurrences. The power 
or nervT)us energy of the heart may be impaired to such an extent as 
to render the patient liable to faintness from very slight causes, — 
anger, fear, surprise, or even the more tender emotions, overcoming 
the patient very readily. 

Respiration. 

The respiratory apparatus is not so frequently or so severely affected 
as some of the rest of the organization, and yet we often meet with 
some very curious and considerable deviations from the natural con- 
dition of its functions. The constriction about the throat, or the 
feeling as if a ball rose to the throat and obstructed respiration, and 
the feeling as if smoke or dust was in the air which the patients 
breathe, are complaints we hear almost every day. All these sensa- 
tions, or any one of them, may be aggravated to an agonizing degree, 
inducing the fear that the paroxysm may be fatal, and causing the 
patient to suffer for some moments, and sometimes for hours, the 
horrible sensations of impending suffocation. The breathing may be 
spasmodic from painful and unnatural contractions of the respiratory 
muscles. There may also be pleurodynic pains during each ordinary 
effort of respiration. Imperfect respiration, or partial inflation of 
one lung, or of parts of the lungs, occasionally occurs. The modifi- 
cation of the respiratory murmur arising from this imperfect inflation 
of one of the lungs I have observed on several occasions, and not 
without serious apprehension of the result; but in all cases where 
this was the only modification of physical sounds, the patients have 
done well, and the inflation improved as the returning nervous energy 
of the rest of the system was established. The respiration is not often 
hurried as a constant circumstance, but occurs temporarily as the 
effect of excitement from mental or moral emotions. In some cases, 



214 SYMPATHETIC SYMPTOMS OF UTERINE DISEASE. 

amid the tumuli of nervous excitement during a paroxysm, I have 
seen the respiratory efforts increased to sixty in a minute; and, occa- 
sionally, these nervous patients constantly have increased frequency 
of respiration. There are cases in which cough is a very constant 
symptom; it is a peculiar, nervous cough, as a general thing, and Is 
excited or made worse by anything that renders the patient more 
nervous. Sometimes it Is difficult to distinguish it from the coughs . 
which arise from insidious affections of the lungs. It is possible tliat 
the coughs arising from slight lung difficulties may be aggravated 
by the nervousness consequent upon uterine disease. I once saw a 
patient affected with a peculiar nervous cough, as the effect of uterine 
disease, which sounded like the barking of a small dog, and the sound 
was made at every expiration during the waking condition of. the 
patient, except when the mind was intensely occupied. She was an 
intelligent young married woman, about twenty years of age. While 
her whole attention was absorbed, she forgot to cough, but as soon as 
her attention wag relaxed, she habitually produced the same sound. 
This had lasted when I saw her six months or more. .When she was 
embarrassed by a conversation which related to her case, the sounds 
became much louder and persistent, appearing in perfect synchronism 
with every respiratory effort. I must further add that I did not 
have an opportunity to treat this patient, nor have I heard from her, 
so that I cannot give her subsequent history; but the rest of the 
symptoms plainly indicated uterine suffering, and an examination 
established the fact that she had ulceration and inflammation of the 
neck of the uterus. She had never borne children or miscarried. 

Sympathy of the Excretory Organs. 

The excretory organs also sympathize with the uterus, particularly 
the kidneys. It has been for a long time observed that female pa- 
tients. In a state of nervous excitement, secrete a large quantity of 
urine, which is usually limpid, almost odorless, and insipid. These 
qualities are most likely dependent upon the amount of water being 
so much greater proportionately than the salts; these last scarcely 
seem to be present at all. It is extremely dilute urine. Uterine 
patients are very prone to large discharges of limpid urine. This 
kind of alteration in the functions of the kidneys is, doubtless. Indi- 
rect, and does not occur except in connection with a greatly excited 
condition of the nervous system as the medium between the kidneys 
and the uterus. More considerable deviations, however, are apt to 
take place ; the salts are likely to be increased in quantity compared 



MAMMARY BODIES. 215 

to the amount of water; or one sort of the salts may be greatly over 
or under the proper proportions in relation to the others. The urine 
may be decidedly morbid in its composition. It is probable, too, 
that the deviation is secondary to derangements of the stomach and 
liver, but, nevertheless, it is often present. The urine may be highly 
alkaline, or highly acid in reaction, showing the production, to an 
uiuisual degree, of salts having such chemical qualities. The presence 
of the salts in excess, whether of the one kind or the other, is pretty 
sure to produce painful micturition and other disagreeable sensations, 
as burning and smarting in the urethra and bladder. There is no 
doubt, however, that the painful and disagreeable symptoms may 
arise as the more direct effect of inflammation of the uterus when the 
urine is correct in composition; hence the examination of the urine 
will be necessary to determine the cause of the symptoms. But the 
urine is often secreted in very diminished quantities in cases of uterine 
disease, and that, too, without apparent general febrile excitement. 
Patients frequently complain of this symptom. Whether there is an 
increase in the excretory functions of the skin at such time I am 
unable to say. The skin is probably not very much affected in i;:s 
excretory capacity as a general thing, but some very curious devia- 
tions have been observed. 

3Ta m m a ry Bodies. 

More direct are the effects upon the mammary bodies. They are 
often highly excited by uterine disease; this is no more than would 
have been expected from the close sympathetic relations between these 
organs. Congestion is the most common sympathetic condition. The 
mammae increase in size, become hot and painful as a general thing, 
but sometimes there is no change in their sensible or sensitive con- 
ditions. The appearances are natural, but the patient complains of 
a peculiar and painful condition, not unlike the sensations perceived 
during the suppurative stage of inflammation ; but there is neither 
tenderness, nor swelling, nor heat, nor other deviation than the un- 
natural sensation. Sometimes the breasts are really inflamed. The 
lymphatic glands in the axilla, and from the axilla to the border of 
the mammse, in some cases, become affected at the same time; in 
other instances, however, they do not partake in the sympathies of 
the mammae. They also become tender in some cases when the 
mammae do not seem to be excited. 

I have dwelt so long on these general symptoms, and have made 
«o much of uterine sympathies, that I am forced to recall an expres- 



216 SYMPATHETIC SYMPTOMS OF UTERINE DISEASE. 

sion made use of in a notice of Professor Hodge's work on Diseases 
of Women, that " if all this is true, it is almost a pity that a woman 
has a womb;'^ bat I have fallen very far short of mentioning all the 
sympathetic evils resulting from chronic diseases of the uterus, and I 
only design this as an outline view of a subject that will fill itself up 
in painfully warm colors in the observation of those who devote them- 
selves to a close study of the diseases of women. While this is my 
conviction, I do not wish to be understood as saying that nearly all 
of the above symptoms will show themselves even in a majority of 
cases; some of them will be prominent in some cases, others in other 
cases; and in rare instances we meet with nearly all of them in some 
sufferer, and in nearly all chronic cases we shall find enough to move 
us to commiseration for the ruined health of women thus affected. 
I know there are thousands of my peers in the profession who do not 
see in the foregoing array of symptoms any indication of disease of 
the uterus, and when uterine diseases are obviously coexistent, they 
are not arranged in the order of sequency. This does not shake my 
faith in the facts I have observed for myself, nor disturb my judg- 
ment, formed from an observation of a very large number of cases 
carefully watched through all stages of progress to their termination. 
That all the above symptoms may occasionally be present in cases in 
which the uterus is healthy, I have often observed; but that they are 
also present as the proximate and remote effects of uterine disease, I 
am well satisfied. Another well-established fact, according to my 
judgment, is, that the direct symptoms referable to the uterus may be 
feebly pronounced, while some, or even a large number, of the sym- 
pathetic disturbances are very prominent; and, judging by the free- 
dom from pain and other inconveniences in the uterine region, there 
are even cases in which the uterus does not seem to suffer at all. 
These cases are well calculated to mislead us, and to induce the 
opinion that the womb difficulty is of minor importance, and need 
not be the object of solicitude until we get rid of the more trouble- 
some and prominent symptoms. We cannot be too careful in our 
consideration and management of this class of cases, and while we 
adopt judicious remedial means for the removal of the more afflicting 
symptoms, we must address ourselves to the disease of the uterus, 
however slight it may appear to be. I have seen too much good 
result from the observance of this direction not to dwell with emphasis 
upon its importance. The cure of the uterine disease will be a valu- 
able diagnostic measure in such cases. Not only may there be a 
great difference, or want of correspondence, in the severity of the 



MAMMARY BODIES. 217 

local and general symptoms, but in many cases in wliicli the general 
symptoms have almost made a wreck of the health and happiness of 
the patient, the local inflammation and ulceration will be found upon 
examination to be trifling in amount and degree. The inflammation 
may be very slight and the patient snifer very greatly from it, either 
generally or locally, or both; or the ulceration may be extensive and 
the inflammation very considerable, and yet the patient hardly be 
sensible of any inconvenience whatever from its presence. This state- 
ment will be confirmed by careful observers in this field of research. 
This, however, will prove a stumbling-block to those who entertain 
the opinion that uterine disease is of small importance in the consid- 
eration of woman's ailments. They seem to think that there is of 
necessity an exact and invariable seeming correspondence between the 
magnitude of cause and effect, and they point to these cases and say, 
the symptoms were present, but a very trifling, if any, uterine disease 
showed itself upon examination; or, they will say, there was great 
ulceration, but the patient did not sufi^er from its presence, at least 
not in proportion to the amount of local disease. I need not particu- 
larize instances in which other diseases are comparatively latent, or 
cases in which the symptoms are unduly severe compared to the 
amount of actual disease, as they will suggest themselves to every 
intelligent practitioner. But, recurring to the sympathies of the 
uterus, we find that while some patients are not afifected at all by 
pregnancy, and others favorably affected, their health being better 
then than at any other time, that some absolutely perish on account 
of the functional derangements inaugurated by pregnancy; and, as is 
shown on a former page, organic diseases are not unfrequently lighted 
up. We shall probably always be at a loss to understand precisely 
this difference ; but there can be no doubt that it is more on account 
of constitutional differences than local ones. The concatenation of 
sympathetic influences may be caused by the greater susceptibility of 
the organs secondarily affected. In fact, the only mode of account- 
ing for it is by supposing this increased susceptibility. I am con- 
vinced that this great but inexplicable diversity of sympathetic effects 
is as likely to result from uterine disease as from pregnancy. AYe 
must, therefore, expect a very great range of difference in the extent 
of sympathetic derangement from uterine disease. It is interesting 
to observe the rise and development of the sequences to diseases of 
the uterus. How far can the uterus produce a direct effect in creat- 
ing this large amount of sympathetic disorder? Are most of the 
symptoms produced by the direct sympathetic relation of the uterus 



218 SYMPATHETIC SYMPTOMS OF UTERINE DISEASE. 

to other organs, or does the diseased uterus first aifect some other 
more influential oro-an detrimental! v, and then this last the organism 
generally? I am inclined to think, from a large observation, that 
the uterus has close SYrapathv with only a few organs, and no one 
probably is so powerfully affected by it as the stomach. It is the 
first organ affected in pregnancy, being brought into a morbid con- 
dition in a very few weeks. The well-known, powerful, and almost 
universal sympathetic influence exerted by the stomach upon other 
viscera is sufficient, when it is diseased, to account for the great variety 
of subsequent symptoms. The stomach is the great centre from which 
radiate abdominal, thoracic, cerebral, and spinal disturbances almost 
ad infinitum; and there can be no reasonable doubt that it is an ac- 
tive assent in orio^inatins^ the disturbances of the great vital oroans. 
The subject of the sympathetic influence of the uterus then becomes 
the more interesting and important, from the fact that a very slight 
deviation from its ordinary condition arouses the most influential of 
all the organs to a state of disease, which depresses the functional 
energies and increases the susceptibilities of almost all the rest of the 
organism. Tn addition to the chain of sympathetic susceptibilities 
produced by this state of the stomach, frequently the digestive powers 
of that organ are impaired or perverted, so as to supply the chyme 
in deficient quantities or in deteriorated quality, and in this way 
injuriously affect the composition of the blood, inducing anaemia or 
oligsemia. Imperfect nutrition will follow, as a matter of course, in 
the one case, and perverted nutrition in the other, so that emaciation 
or obesity will be ordinarily present. Another organ, probably, in 
direct sympathy with the uterus is the cerebellum, as it seems to me 
to be as frequently affected as the stomach. The mammae are, of 
course, in direct sympathetic relation with the uterus, and yet they 
are not uniformly affected in all cases when the uterus is very seriously 
diseased. I do not believe that we are able to say at present whether 
there are other organs that come directly under uterine influence. 
A proof of the powerful and very ready effect upon other organs, of 
irritation of the uterus, may be found in the fact, that very often 
when the patient is in a condition of comfort, so far as her general 
suffering is concerned, an application of nitrate of silver to a morbid 
OS uteri will giv^e her excruciating pain in the head, render her 
exceedingly despondent and irritable, and very much aggravate the 
symptoms with which she is affected. This I have so often observed 
to be the case that I cannot but res^ard it as one of our diao^nostic 
means. After such an application, the patient will generally com- 



INABILITY TO WALK. 219 

plain of an aggravation of the general pymptoms, whatever they may 
have been, and say that all the pains are made worse by the applica- 
tion of the caustic. When an organ has been the subject of irritation 
or functional derangement for a long time, in consequence of sym- 
pathy with the uterus, it may become the subject of organic disease, 
which may continue as an independent affection of, perhaps, a dan- 
gerous character; or, if organic has not succeeded to functional dis- 
ease, the power of habit, which is so frequently thus engendered, will 
perpetuate morbid action for an indefinite period after the cause of it 
has been removed. 

LOCAL SYMPTOMS. 

Pain in the Sacral or Lumbar Region. 

Pain in the sacrum is one of the most constant, and when persistent 
indicates, with a good deal of certainty, disease of some kind in the 
pelvis. The pain in this region, caused by the diseases of the uterus, 
is ordinarily central, being in the middle of the sacrum at its lower 
extremity. It is sometimes at its upper extremity, or it extends the 
whole length of the bone. N^ot unfrequently a painful spot may be 
found on one side, over the sacro-iliac junction. Some patients de- 
scribe the pain as if a bundle of nerves were pulled upon from the 
inside of the sacrum, and others describe it as an aching or burning 
pain. Accompanying the pain in the sacrum is often a sense of sore- 
ness upon pressure, an inability to sit with comfort, on account of 
the tenderness of the lower part of the sacrum. 

Pain in the Loins. 

Pain in the loins is probably not so common as that in the sacrum, 
but is quite as various in its nature. Very frequently there is great 
weakness in the loins, so great in degree sometimes as to prevent the 
continuance of the erect posture for any length of time. I have had 
a number of patients who were unable to stand long enough to dress 
their hair on account of a w^eak back. 

It is remarkable that patients often feel this weak back more when 
standing than when walking; and they are sometimes able to w^alk 
a distance without any great inconvenience, but as soon as they stop, 
the weakness is apparent to a distressing degree. 

Inability to Walk. 

Ordinarily the weakness disables the patient for walking. The 
pain in the back is almost always increased by walking or standing, 



220 LOCAL SYMPTOMS. 

and on this account the patients avoid being on their feet, although 
the back is strong enough. But there are many patients who have 
severe disease of the uterus, who do not experience any of the incon- 
veniences in the sacrum and loins already described; but some of 
them are very generally present. 

Great pain in the back, closely resembling that arising from a dis- 
eased uterus, is also caused by haemorrhoids, prolapse, or inflamma- 
tion of the rectum. The pain caused by diseases of the rectum, I 
think, is much more frequent on the left side of the sacrum and in 
the left nates or hip than in a central position ; in fact, I have come 
to regard pain, confined to the left nates and hip, as indicating, with 
considerable probability, rectal disease, and I always inquire into the 
functions of that organ Avhen such pain is present. It differs in po- 
sition from the pain in the iliac region, so common as the result of 
uterine disease. It is situated near the sacrum, and more in the side 
of the pelvis than the latter. 

Pain in the Iliac Region. 

Pain in the iliac region is very common. In frequency it is next 
to pain in the back. The pain is commonly situated a little anterior 
to the superior spinous process of the ilium, and below the level of 
it. It is not referred to the iliac bone, or fossa, but to a place a little 
above the groin. We often meet with it on both sides, but much 
more frequently on one only; on the left side much oftener than on 
the right. Dr. Dewees considered pain in the left groin, or a little 
above it, as almost diagnostic of prolapse of the uterus. It is cer- 
tainly very frequently indicative of inflammation of the uterine cervix. 

Soreness in the IUac Region. 

This pain is generally accompanied with soreness upon pressure, 
and sometimes there is soreness upon pressure when there is no con- 
stant pain. Walking, standing, or riding generally increases it. A 
severe shock or strain from lifting will sometimes cause pain suddenly 
to appear in this region when it had not before been observed. 

Pain in the Side, above the Rium. 

Instead of the pain situated as here described, there is often pain 
higher up in the side, or in the iliac fossa, or along the crest of the 
ilium, and even midway between the crest and ribs of the side. These 
pains are not in the ovaria, although they seem to point to the ovaria 



LEUCORRH(EA. 221 

more directly than to tlie uterus, and are by some regarded as a symp- 
tom arising from ovarian inflammation. Dr. Bennett admits that it 
may be a sympathetic painful condition of the oyary. It is not ma- 
terial whether this is true or not ; it is certain that it is very frequently 
present in uterine disease, and is almost invariably cured by remedies 
addressed to the uterus instead of to the ovaria. 

Weight, or Bearing-down Pain, or Uterine Tenesmus. 

Another indication of uterine disease, of less frequent occurrence, 
is a sense of weight in the loins or pelvis. This sense of weight is 
experienced in the loins and iliac regions more frequently than else- 
where; but it is often felt at the pelvis, and oftener in the perineal 
and anal regions. Patients express themselves as feeling a heavy 
weight dragging upon the back and hips, and others feel as though 
the insides were dropping through the vagina. Occasionally we meet 
with such urgent uterine tenesmus that the patient is obliged to keep 
the recumbent posture in order to enjoy any comfort. In such cases 
the patient in the erect position cannot resist a constant desire to 
^'bear down,'^ resembling the tenesmus of dysentery. This sensation 
is sometimes more distressing than any other symptom, and obliges 
the patient to desist from walking. 

Leucorrhoea. 

Leucorrhoea is one of the symptoms usually relied upon as an evi- 
dence of disease of the uterus. In the healthy condition of the uterus 
and vagina there ought to be no discharge; the vaginal canal is 
merely moist, and no mucus should make its appearance externally. 
When the mucous membrane is temporarily excited, there is more 
than ordinary secretion ; but it ceases as soon as the cause of excite- 
ment passes. 

We should a priori expect increased vaginal discharge to be ac- 
companied with some form of disease, especially when it continues 
for more than a few days. Our knowledge of the discharge from 
mucous membranes lining the cavities elsewhere will afford us enough 
data to confirm these views. We do not expect to see a constant flow, 
however moderate it may be, from the male urethra when it is per- 
fectly healthy; and we take gleet as an evidence of chronic urethritis, 
and it is generally the sequence of an acute attack of that disease. A 
constant discharge from the nose is an evidence also of more or less 
disease. It is just so with the vagina. The indications from leucor- 



222 LOCAL SYMPTOMS. 

rhoea are derived from the color or consistence of the discharge, or 
both. The discharge from the vagina, resulting from mere excite- 
ment of the vaginal crypts, is thin, glairy, and not very tenacious. 
It is ordinarily acid in reaction. There is no color, and but little 
consistence to it. When a moderate excitement of the internal mu- 
cous membrane of the neck of the uterus produces a discharge of 
mucus, sufficient to appear at the orifice of the vagina, the discharge 
is white, not unlike milk, and when examined closely, will be found 
to consist of minute coagula swimming in a little clear fluid. When 
the mucus flows from the mouth of the uterus it is thick, and resem- 
bles very closely the albumen of an egg, and is alkaline in reaction. 
When it passes into the vaginal canal, it meets with the acidity of 
the vagina and is coagulated, and the whole changed from a colorless 
translucency to an opaque white. The reason that the coagula are 
small and so numerous may probably be found in the fact that the 
mucus arrives in the vagina in such small quantities; each coagulum 
represents a minute drop of mucus, changed in quality. As, how- 
ever, the mucous membrane of the vagina furnishes only a small 
quantity of acidity, when this alkaline discharge from the cervix is 
copious it soon neutralizes the vaginal acid, and passing through this 
cavity unchanged, appears at the external parts possessing its charac- 
teristic qualities. We then hear the patient complain of a tenacious 
albuminous leucorrhoea; she will nearly always compare it to the 
white of an egg, but state that it is more tenacious. Unless the 
quantity is considerable, the mucus from the internal cervical mem- 
brane does not appear at the external orifice unchanged, but passes 
into this curdled condition. There is often a considerable quantity 
of this creamlike leucorrhoea in the whole length of the vagina, and 
hence it has been supposed by many that this is the vaginal mucus 
in its natural condition, and they have called it vaginal leucorrhoea. 

Amount of Leucorrhoea not always Proportioned to Extent of Disease. 

The abundance of this discharge is no criterion by which to judge 
of the amount of disease or its intensity, but it will scarcely remain 
colorless after the integrity of the membrane is invaded. When the 
albuminous fluid appears at the orifice of the vagina, there is per- 
sistent cervical disease almost of a certainty. 

Yellow Leucorrhoea, xchen there, is Abrasion or Ulceration. 

The thick, white, or egglike albumen will be mixed, when there 
is ulceration in the cervix, to a greater or less extent, with pus, so 



■M 



BEARING DOWN NOT CAUSED BY DISPLACEMENTS. 223 

that it will be stained yellow^; if the quantity of ulceration is consid- 
erable and its surface is producing pus, the yellow will preponderate 
in the color, and sometimes the whole of the production becomes yel- 
low. The yellow color may be in streaks through it, or intimately 
mixed with it, so as to stain it uniformly; or the pus may be mixed 
with the white, creamy secretion found in the vagina. Pus may be 
mixed with any of the varieties of leucorrhoea, and impart to it its 
tint more or less completely. 

How is the Fain Produced.^ 

How are the local, painful symptoms produced ? Is the pain in 
the groin or ilium caused by prolapsus, and traction on the broad or 
round lio^aments? I think not. Pain and sensitiveness in the ilium 
are so frequently present — when I cannot detect any kind of displace- 
ment, and so generally disappear when the inflammation or conges- 
tion is cured — that I am convinced displacement is not necessary for 
their production. They are of that character of pains which range 
themselves in the category of the vague, yet indispensable term, sym- 
pathetic, and are perhaps in the ovary; or, of the not less fashion- 
able, yet equally indefinite term, reflex. 

Bearing Down not always Caused by Displacements. 

The sense of weight or bearing down in the pelvis is one about 
which there w^ould, from its nature, seem to be no doubt as to its 
origin being in displacement. It gives the patient the idea that the 
womb is bearing w^ith unusual weight on unusual places, viz., the 
perinseum, the rectum, or the bladder; and yet, in a great many in- 
stances, we shall fail to detect any deviation from the natural position 
of that organ; and, as soon as the inflammation is cured, the symp- 
tom vanishes without any treatment with reference to displacement. 
How can we account for this symptom? I think its explanation 
may be found in the fact that the pelvic organs, on account of the 
general pelvic, vascular turgescence, are unusually sensitive and re- 
ceive painful impressions from contact, which, in the absence of these 
conditions, would have no effect in causing inconvenience of any kind. 
Moderate prolapse, retroversion, or other displacement, when unat- 
tended by congestion or inflammation, may exist for a long time with- 
out giving rise to any disagreeable sensation whatever. When the 
uterus is slightly displaced, with considerable pain and sense of weight 
accompanying this condition, the displacement is commonly considered 



224 LOCAL SYMPTOMS. 

to be the cause of the distress. When, however, the uterus occupies 
a normal position, and a sense of weight and pain still exists, it is 
regarded by most practitioners as the result of an "irritable uterus.' 
That the uterus is sensitive, "irritable," if the term suits better, there 
is no doubt; but that it is ever so without congestion or inflamma- 
tion I do not believe. 

Severity of Suffering not Commensurate with Amount of Disease. 

The great error in the estimate of the importance of uterine in- 
flammation is in endeavoring to measure the amount of inflammation 
by the severity of suffering, in assuming that because the woman 
suflers a great deal there must necessarily be extensive inflammation 
or ulceration. I believe I have seen more nervous prostration, more 
keen suffering, and have heard louder complaints from a small amount 
of endocervicitis than from extensive and obvious external ulceration. 
Pelvic congestion and increased sensitiveness of the viscera contained 
in the pelvic cavity, caused by a small amount of persistent inflam- 
mation in the neck of the uterus, calls into action, in an exaggerated 
and intensified form, all the sympathies which are excited by the 
uterus in its physiologically congested condition, and its persistence 
wears the more upon the general organism on account of the increased 
sensitiveness produced from day to day by virtue of its chronicity 
alone. It is anticipating what I shall say in the chapter on progno- 
sis, to state that endocervicitis is not only more difficult to cure, but 
more destructive to the health and happiness of the patient than in- 
flammation and ulceration external to the os. Indeed, we often find 
cases of extensive ulceration very apparent through the speculum, 
and consequently entirely unmistakable to the most careless observer, 
which produces less inconvenience than an amount of endocervicitis 
so small as to escape the attention of any but an experienced gynae- 
cologist. This fact is perplexing, but the knowledge of it will cause 
a proper appreciation of what is apparently a trifling matter. 

Effects on the Functions of the Uterus. 

Having given the foregoing sketch of the general and local symp- 
toms of congestion and inflammation of the uterus, I purpose to 
glance at the effects produced on the functional action of that organ. 
The first function assumed by the uterus and the last it continues is 
menstruation. It becomes a matter of interest to the physician to 
ascertain the cause of deviations in a function so persistent, so general, 



EFFECTS OF PARTIAL CLOSURE OF THE OS UTERI. 225 

and so important to the liealth of woman. As hypersemia is the 
cause of injurious and even destructive tissual changes and of func- 
tional aberrations in the vital organs much more frequently than any 
other ])athological condition, so I think that the functional aberra- 
tions of the uterus particularly depend much more frequently upon 
it than upon any other cause. 

Pain during Menstruation, 

Pain during menstruation is not necessarily attended by deviation 
from the normal monthly flow. That there are varieties of dysmen- 
orrhoea or painful menstruation, with unusual quantities and extra- 
ordinary kinds of discharge, is true; but, in many instances, the 
discharge, though accompanied with pain, is right as to its character 
and quantity. 

Kind of Pain attendant upon Uterine Inflammation. 

The kind of pain attendant upon uterine inflammation is, for the 
most part, the same in quality, but varying in intensity. It is a 
continuous sore pain, with heat in the parts, sometimes so slight as 
to give the patient very little inconvenience, and it varies from this 
to pain of great severity. The pain is at times sufficient to cause the 
patient to keep her bed for several days, and sometimes for the whole 
period of the menstrual flow; occasionally it amounts to agony, pros- 
trating her by a paroxysm which may last for hours, or even several 
days. 

Cramping Pain. 

Instead of this continuous sort of pain, of varying intensity and 
duration, there are less frequently painful throes "coming and going,^' 
like labor-pains or after-pains. This kind of pain is often mistaken 
for colic. They are often very severe, and may last a few hours or 
several days. They may depend on some substance contained in the 
uterus, as shreds or membranes of fibrous exudation, and cease at 
their expulsion. But oftener no such cause can be discovered in the 
evacuations; nothing can be found but fluid blood, or coagula evi- 
dently formed in the vagina. In other cases the os uteri internum 
is small, and does not readily admit the passage of the uterine sound. 

Effects of Partial Closure of the Os Uteri on Menstruation. 

Many practitioners believe that this condition of the os internum, 
by preventing the ready flow of the blood, causes it to accumulate 

15 



226 LOCAL SYMPTOMS. 

until the quantity is sufficient to arouse expulsive efforts for its ex- 
trusion. In a lai-ge majority of cases I have had the opportunity of 
observing, there was no coarctation ; and in several of the worst 
cases I have met with, the os internum allowed the sound to pass 
with so much freedom that I could not distinguish its locality. It 
is also true that in many cases in which the os externum was not 
larger than a small pinhole, the patients menstruated without any 
pain whatever. By far the most frequent causes of dysmenorrhoea 
from obstruction I meet with are in connection with flexions of the 
uterus. I can easily understand that a sharp curvature in the cervix, 
or at the junction, will prevent the free efflux of the menstrual fluid. 
In such cases the pains resemble labor-pains, and are, doubtless, of 
the character of uterine contractions. The pain from inflammation 
may occur at any time during the menstrual flow^, and before and 
after it. Not unfrequently a paroxysm of severe pain, lasting several 
hoars or a day, warns the patient of the approach of the discharge, 
and subsides suddenly and completely, or gradually and incompletely, 
as soon as the discharge is fairly established. Frequently the pain 
continues during the wdiole time of menstruation, beginning shortly 
before or synchronous with the discharge, and subsiding with it, 
though in occasional cases it continues after it. We sometimes meet 
with patients who begin to menstruate without any suffering, but 
who have pain during the flow, or after its discontinuance. I think 
that a majority of patients affected with uterine disease have some 
pain during menstruation ; but there are some who have none what- 
ever, and pass through their period with little or no suffering. 

Planner of the Flow modified by Inflammation and Congestion. 

The manner of the flow is often modified. Instead of the con- 
tinuous flow, commencing moderately, gradually increasing, and then 
as gradually declining, every manner of deviation almost may exist. 
With some, the discharge begins naturally, increases very rapidly, 
until at the end of twenty-four or thirty-six hours an average amount 
is lost, and then the discharge suddenly declines and ceases, or con- 
tinues in very moderate quantity for a time longer, and gradually or 
suddenly stops. With others, the flow may begin and proceed nat- 
urally for a day or two, cease for one or two days, and then reappear 
and flow freely for a sufficient time. When menstruation proceeds 
in this way, it is generally attended with pain. These two varieties 
are more frequent than any other. 



AMENORRH(EA. 227 

Duration of the Flow. 

The duration of the flow may not be affected by it. The flow may 
continue three weeks or the whole month. This, however, is not 
frequent. It does not much afi'ect the periodicity of return, of 
menstrual congestion and effort; but it is not unusually the case that 
we cannot distinguish the discharge which attends ovulation from the 
haemorrhage which proceeds from an ulcerated surface, as hsemor- 
rhagic congestion is so constantly present. We often meet with 
patients who are so confused by the frequent irregular returns of 
uterine haemorrhage that they lose all reckoning as to the time for 
the menstrual return. Occasionally, continuous haemorrhage is present. 
The most frequent deviation from regularity in menstruation consists 
in a slight anticipation of the time of its return. 

Menorrhagia, 

Menorrhagia, or haemorrhage at the menstrual period, is not an 
unusual functional deviation. The haemorrhage is often very con- 
siderable and continues after the usual period has passed by. The 
flooding is usually greater while the patient is in an erect posture, 
and it is greatly moderated by recumbency. Occasionally, however, 
it is not moderated by this means. It would seem probable, a priori, 
that menorrhagia would be the rule with patients aff^ected with 
uterine inflammation, but such is not the case. I am not sure that 
even a majority of patients have it. 

Menorrhagia frequent in Endocervicitis. 

I have observed that menorrhagia occurs much more frequently in 
patients when the inflammation occupies the cavity of the neck ; this 
also is the case with painful menstruation. All cases in which there 
has been either great pain or haemorrhage, or both, for they are fre- 
quently coexistent, have been, in my observation, cases in which en- 
docervicitis is the principal disease. Menorrhagia is not always the 
result of inflammation of the uterus, though inflammation is its most 
frequent cause ; and in such cases it cannot be cured without first 
curing the inflammation. 

Amenorrhoea sometimes Results. 

Amenorrhoea is the least frequent of menstrual deviations as the 
effect of inflammation or congestion of the uterus ; but this inflam- 
mation is frequently the cause of scanty menstruation. It is curious 



228 LOCAL SYMPTOMS. 

to Dote the manner in which this scantiness occurs. It seems to come 
on after the inflammation has lasted for a considerable time, and is 
almost always associated with sterility. In cases I have watched for 
some time, the organ was atrophied and rendered less vascular and 
erectile ; probably on account of a deposition of fibrin throughout 
the general structures of the uterus. The scantiness is sometimes 
attended with irregularity, which consists in postponement or length- 
ened intervals. I treated one patient for endocervical metritis, in 
whom the uterus did not appear to be, as far as I could measure it 
per vaginam, more than one inch and a half in length, and corre- 
spondingly small in the other dimensions. This patient would men- 
struate sometimes only a day every month, and discharge but half an 
ounce of blood each time, and occasionally the discharge would not 
return for five, six, and even nine months. In early life her menses 
had been regular in quantity, quality, and times, and unattended 
with pain. She was barren, having never conceived, as far as she 
was aware. She dated the beginning of her disease from vaginitis 
during an attack of fever, which occurred two or three months after 
marriage. 

Function of Generation affected by It. 

The great function for which the uterus was formed, that of gen- 
eration, seems very frequently to be disturbed by inflammation of 
the neck of the uterus. Some practitioners think, because a woman 
bears children with frequency, the uterus cannot be much diseased. 
This is unquestionably a mistake. I have known many women with 
extensive ulceration to bear children very frequentlv, but there is 
always great liability to embarrassment of the function in such cases. 
Conception may be entirely prevented by inflammation, or gestation 
may be arrested by miscarriage, or labor may be rendered difficult by 
it ; and there is no doubt that many cases of sterility depend wholly 
upon inflammator}' action about the neck. 

Sterility, 

Sterility is attended by different circumstances. Some women are 
sterile their whole lifetime ; others, after having borne children to 
the full period and given birth to them, become sterile for years, or 
for the whole of their subsequent life ; others again become pregnant 
soon after marriage, miscarry at an early period, and never again con- 
ceive. In many cases of sterility which I have had the opportunity 
of examining, I have found evidence of inflammation in the cervical 



ABORTION. 229 

cavity. Very often the inflammation is confined to this cavity. The 
history of these cases showed that congestion and inflammation had 
existed from the time of menstruation ; these were cases in which 
conception had never taken place. In cases of sterility in which 
the women have become sterile after having once borne children, 
ulceration is usually situated around the os, extending upward into 
the cavity of the neck. This is almost certain to be the case if the 
woman has borne several children. When the patient has miscarried 
but once, there is not likely to be external inflammation to any great 
extent ; but if there have been several abortions, the ulceration is apt 
to creep out and manifest itself upon the labia uteri, and sometimes 
becomes very extensive. Although the foregoing statements, with 
reference to the position and extent of ulceration in sterility, will 
generally be found to correspond with the appearances, yet we must 
not be surprised to find pretty extensive ulceration external to the os 
uteri in the originally sterile patient ; and in those who have borne 
children and become sterile afterward, we shall sometimes find no 
external ulceration. The result of my observation is, that when 
sterility originates in uterine inflammation, it is in that form of it 
known as endocervicitis. Sterility often depends on the condition 
and quality of the leucorrhoea. In many of these cases the secre- 
tions from the vagina are very abundant and intensely acid, so as to 
produce irritation of the external organs. Although the semen is 
diluted and defended from the influence of acid vaginal secretions, 
by mucus of alkaline reaction, yet when these vaginal secretions are 
abundant and possess strong chemical qualities, they may destroy the 
vitalizing influence of the seminal fluid, and thus prevent fructifica- 
tion. Or the very thick, tenacious, albuminous fluid, which some- 
times plugs up the OS uteri and whole cervical cavity, may prevent 
the ingress of the spermatozoa, which, by their independent motion, 
according to present belief, penetrate the uterus, meet the ovum some- 
where on its passage to the os uteri, and produce their fructifying in- 
fluence upon it; and thus is precluded the possibility of eifective 
insemination. 

Abortion. 

But conception may readily occur and pregnancy be complete, and 
after gestation has continued for a certain time abortion may take 
place. Abortion is a very frequent effect of inflammation and ulcer- 
ation of the OS and cervix uteri. The seat of inflammation or ulcer- 
ation which most frequently induces it is inside the cervical cavity- 



230 LOCAL SYMPTOiMS. 

We find some patients who have aborted very frequently and never 
had a full-term child ; others, who have had one or rnore children, 
but who miscarry every pregnancy afterward ; and again, others who 
miscarry frequently and occasionally go to full term. It is not strange 
that miscarriages should result from this cause; a priori, miscarriage 
might be regarded as its necessary effect. Nevertheless, many patients 
bear children at term who labor under severe ulceration, and who are 
prostrated by the constitutional sympathies accompanying pregnancy. 

Conditions of the Uterus in Abortion. 

Two general conditions of the uterus exist as the effect of cervical 
inflammation, and are probably the proximate causes of abortion, viz., 
congestion or arterial injection of sufficient strength to cause haemor- 
rhage; and, perhaps, by means of insinuation of the clots, separation 
of the placenta, or irritability of such a nature occurs that contraction 
and expulsion follow conception ; or, perhaps increased sensitiveness 
of the mucous membrane may increase its excito-reflex influence so 
as to arouse uterine contraction, and thus cause the foetus and mem- 
branes to be expelled. When abortion is caused by congestion, it is 
apt to be ushered in by haemorrhage. The hsemorrhage, after con- 
tinuing for a varied length of time, from a few hours to several days, 
is followed by uterine contractions. When abortion is the result of 
increased irritability, the first symptom is contraction, with the par- 
oxysmal pains attendant upon it. This continues for a time, when 
haemorrhage and expulsion succeed. When abortion occurs once, it 
is very likely to recur in every subsequent pregnancy about the same 
time, until the disease is cured upon which it depends. While abor- 
tion is very apt to recur in the congestive or haemorrhagic variety, it 
is generally not so exact in the time of recurrence. This variety, 
however, takes place more frequently at the time when the monthly 
congestion is present, while the other is independent of such influence. 
The probability is, that in the congestive variety the foetus perishes 
before expulsive efforts arise; while in the other the foetus is not 
affected until the contractions have continued long enough to partially 
separate the placental attachments. Whatever doubt, however, may 
exist in all this, there can be no question as to the injurious effect 
produced upon gestation by ulceration or inflammation of the cervix 
uteri. Mr. AVhitehead, of Manchester, England, has written a book, 
full of information, almost solely to illustrate this consequence of 
uterine inflammation. 



EFFECTS UPON THE POST-PARTUM CONDITION. 231 

Effect upon Labor. 

The effect which inflammation of the uterus exerts upon labor is 
not so apparent as upon the progress of gestation. Although I have 
watched patients whom I knew to be laboring under inflammation 
of the neck of the uterus in parturition, I have not been able to per- 
ceive any increase in suffering or tediousness. 

Even when induration and hypertrophy were both of several years' 
standing, no ill effects from them, so far as I could see, attended labor 
either at full term or prematurely. I have observed cases of abortion 
occurring in such patients quite as readily, and with as few trouble- 
some symptoms, as in one whose uterus was healthy. The general 
tissual changes going on in the uterus would lead us to expect this 
in advanced pregnancy, but I confess to some astonishment at having 
seen kindly, rapid, and complete dilatation in abortion at the early 
periods. It is equally singular to see the return of the induration 
after the involution of the uterus is fairly completed. One would 
suppose that the softening accompanying pregnancy would be per- 
manent, and this is usually the case. I have not observed in such 
cases that the abortions were attended with more haemorrhage, or were 
more tedious or painful, than when they occur as the result of some 
transient cause. 

Effects upon the Post-partum Condition. 

Of its effects upon the childbed or post-partum condition, a favor- 
able opinion cannot be given from my observation. A good getting- 
up is not to be expected with much confidence in patients affected 
with uterine disease. The most common effect in childbed is retard- 
ation of the processes of involution. The congestion consequent upon 
labor is protracted, the uterus remains larger and more sensitive than 
is usual, so that instead of the organ recurring to its primitive dimen- 
sions and susceptibility in one month, two or more may be required. 
The lochia, instead of subsiding in fourteen or twenty-one days, con- 
tinues for weeks, or even months, after it should have subsided, and 
when it goes off it is apt to merge imperceptibly into leucorrhoea, 
which becomes persistent. Inability to walk or stand without great 
distress is the effect of the size and sensitiveness of the organ. A 
sense of bearing down, or of weight in the pelvis, pain in the sacrum, 
down the sciatic nerve or in the hip, harass the patient greatly, and 
these symptoms pass off so slowly that she is kept in bed an unusual 
length of time. Acute metritis not unfrequently supervenes, or acute 



232 LOCAL SYMPTOMS. 

inflammation of the cellular tissue at the side of the uterus. Phlebitis, 
pyasmia, and phlegmasia dolens are more likely to arise in patients 
^vho have chronic inflammation of the cervix. 

On the other hand, it is a fact that these subsequent acute inflam- 
mations sometimes operate very favorably upon the chronic affections. 
Instances are not uncommon of patients being entirely cured by the 
effects of gestation and labor upon the tissue of the neck and its 
mucous membrane. We are to hope for this favorable result only 
as a remote probability, because, as already stated, the condition of 
the parts is generally left in statu quo, or, if any difference is percej)- 
tible, it consists in an aggravation of the disease, and the patients get 
up from childbed rather worse than better. 



CHAPTEK XIV. 

PATHOLOGY OF HYSTEROPATHY. 

"What are the pathological conditions giving rise to sucli numer- 
ous and diverse symptoms? 

In answering this question it should be remembered that in con- 
sequence of the nervous and vascular connections and the one great 
function to which they all contribute, physiologically and patholog- 
ically, almost all of the pelvic viscera are a unit. 

From the ovaries to the perinseum the genital organs are largely 
supplied with the same system of vessels and nerves, and are presided 
over by the same genito-spinal centre, and they all have for their bo- 
ject the same general purposes, — generation. 

In ovulation, menstruation, conception, pregnancy, parturition, 
lactation, and involution they all participate, and are in a continual 
state of chano;e. The rectum and bladder are continuallv influenced, 
physiologically and pathologically, by the same conditions, and in 
return reflect their own changes back upon the genital organs proper. 

All the genital organs are thus bound together as one great and 
complete system set apart for one grand purpose, — generation ; sub- 
ject to derangements that may begin in any one part or organ, and 
produce disorder in all the rest. Acting as a whole in the function 
of generation, this extensive and perpetually active system reacts with 
great energy through its spinal centre upon the whole organism. 

I have already in one example quoted from Dr. Tyler Smith — 
and similar cases are continually occurring — shown how vast and 
potent are the sympathetic effects produced by pregnancy upon the 
system at large. 

In a state of disease this great system is as powerful in causing 
morbid symptoms and changes. 

This view of the comprehensive nervous and vascular interde- 
pendence of the pelvic viscera, and their united influence upon the 
whole body, explains how the disease of any one of them may originate 
and perpetuate the general and local symptoms enumerated under the 
terms sympathetic nervous symptoms, hystero-neuroses, genito-uri- 
nary neurasthenia, etc. And we are obliged to give full scope to this 
idea in all our estimates of the very complex functional and organic 



234 PATHOLOGY OF HYSTEROP ATHY. 

diseases of the female organs of generation, if we ^\'Ould arrive at 
correct indications for treatment. 

The essential pathological conditions of the pelvic organs upon 
which the reflex sufferings of the general system are founded are the 
hypergemia and the hypersesthesia of those organs. Without in- 
creased sensitiveness or increased vascularity of them there can be 
no general suffering. This proposition is proveu by the testimony of 
the best authors and teachers everywhere. 

The more marked form of hypersesthesia is for the most part con- 
fined to the urethra, vulva, perinseum, anus, and coccyx : vaginismus, 
anal fissure, urethral caruncula, coccygodynia. Sometimes there is 
hypersesthesia of the vagina and vaginal cervix uteri. These will 
be described in their proper place. 

In studying the subject from a clinical point of view the practi- 
tioner will find disease of the ovaries or uterus the starting-point of 
all these sympathetic derangements more frequently than all other 
pelvic affections, and consequently it is very important that we should 
have a clear view of their pathology. 

AVhile the ovaries in many respects are paramount in their influ- 
ence on the pelvic organs, it is to diseases of the uterus we must look 
for an explanation of the great majority of sympathetic ailments 
above described. 

Xow what is that essential pathological condition of the uterus 
which causes these symptoms ? One condition seems to be present 
more frequently than any other, and that is hyperemia. The enlarge- 
ment of the uterus, as well as the hypersesthesia of that organ, gen- 
erally depends upon hypersemia, and the sympathetic influences of 
the uterus are excited through the system of nerves that accompany 
and control the vascular system, — the vaso-motor nervous system. 
Displacements, flexions, and lacerations do not produce any general 
disturbance except when attended with hypergemia. This statement 
is made in a direct or indirect manner bv almost all of our best 



g} 



nfficolocrist 



& 



Dr. Emmett savs r 



"A version, as has been stated, may exist for an indefinite period 
without causing any disturbance so long as the organ does not prolapse 
sufficiently to increase the existing obstruction to the circulation." 

Witli reference to lacerations he savs : 

* Principles and Practice of Gynaecology, pp. 309, 462. 



PATHOLOGY OF H YSTEROP A TH Y. 235 

"Sometimes the laceration heals while the woman remains in bed 
after labor, but if the surfaces should not heal before she gets up they 
will soon become the seat of extensive erosions, which bleed readily. As 
the uterus increases in size a profuse cervical leucorrhoea follows, and the 
appearance of a frequent show causes the patient to seek relief. She 
will complain of inability to stand with comfort, of a continual head- 
ache, with pains down her limbs, sometimes irritation of the bladder, and 
as a rule marked nervous disturbance." 

And again on page 467 : 

" The uterus, from increased weight, and while resting on the floor of 
the pelvis, will, by traction on the cellular or connective tissue, obstruct 
the circulation sufficiently to produce not only increased congestion of 
the organ itself, but also of the neighboring tissue." 

These Cjuotations show that Dr. Emmett believes that the effects of 
displacements and lacerations are to produce and keep up hyperemia, 
congestion of the uterus, and through this condition to cause all the 
local and general symptoms. 

The object of all his treatment preparatory to uniting the surfaces 
of a laceration of the cervix is to relieve the hyper^emia by giving 
freedom to the circulation of the uterus and making local applica- 
tions to the erosions. When all of this is done the symptoms sub- 
side, and the cure of the laceration renders the cure permanent. 

Hypersemia is not often an independent affection. It is, in fact, 
generally the result of some antecedent etiological lesion, and may be 
removed by getting rid of the cause. It does, however, occasionally 
stand independent of any other lesion, and may be cured by measures 
having no other object in view than the removal of the hyperBemia. 

Xow what is this hypersemia ? There are undoubtedly several 
forms. 1. Active hypertrophic hypersemia, as in pregnancy, the 
earlier conditions of subinvolution, the presence of fibrous tumors, 
or granular degeneration of the mucous membrane. 2. Passive, 
venous, or congestive hypersemia, as where the uterus is displaced or 
flexed, and the blood confined to the fundus or other portion of the 
organ by constriction of the veins, or where effusions around the 
uterus prevent the free outward flow of the blood. 3. Inflammatory 
hyi^raemia. These are the most common and easily determined 
forms, and will serve as examples of hypersemia. All these forms 
may become chronic, and all of them when of chronic duration pro- 
duce changes in the fibrous structure of the uterus. 

It is impossible for them to remain simple hypersemia, because the 



23G PATHOLOGY OF B Y5TER0P ATHY. 

abundant supply of arterial blood in the active forms of congestion 
produces hypertrophy of some of the tissues that enter into the struc- 
ture of the walls of the uterus, and in others gives rise to neoplasms. 

In the passive and inflammatory forms of hypersemia there neces- 
sarily occur fibrino-plastic effusions, which, after coagulating, become 
organized in a low degree, causing not hypertrophy, but induration 
and condensation, Avhich finally cuts off the capillary circulation. In 
these cases the connective tissue formed by this low organization of 
fibrino-plastic effusion supplants the natural structure of the uterus 
to a greater or less degree, and is what I understand by hyperplasia. 

After the uterus is thus changed in structure it is sometimes im- 
possible to restore it to its natural condition. These indurated uteri 
unfortunately are not deprived of their sensitiveness; in most cases, 
in fact, there is hypersesthesia, and as a consequence they are the 
source of extensive reflex mischief. 

In the inflammatory form of hypersemia there are often circum- 
scribed points of induration in the cervix, in the anterior or posterior 
walls of the fundus, owing to the locality in which the vascularity is 
most protracted or intense. 

After the effusion and induration is established the active inflam- 
matory condition may subside, leaving the part in a state of indura- 
tion and hypersesthesia. Thus we find nodules of hardened tissue, 
not the seat of inflammation, but the consequence of that process. As 
a rule, these nodules may be removed when properly treated, es- 
pecially if they exist in the cervix. The deposits thus occurring 
frequently distort and deform the cervix, rendering one portion more 
prominent than others. 

It should be borne in mind that these conditions do not indicate 
the presence of inflammation, but its effects. They give rise to the 
same sympathetic symptoms and suffering that are noticed in other 
forms of uterine disease. 

It is too narrow a view of the pathology of uterine disease, there- 
fore, to apply the term congestion to all these forms of hyperasmia. 
To complete this very cursory statement in reference to the different 
forms of hypersemia, it is necessary to trace somewhat further the 
changes they all may, and generally do, bring about. During the 
progress of all these hypertemige, the mucous membrane undergoes 
notable changes. One of these changes is the so-called ulceration. 
I use this phrase ^'so-called'' in imitation of those who deny the 
existence of ulceration. 



PATHOLOGY OF H YSTEROPATH Y. 237 

Xow ulcer means a sore, and is defined by Danglison to be ^^a 
solution of continuity in the soft parts, of longer or shorter duration." 

Is a solution of continuity of the epithelium an ulcer? Abrasion 
is a term used by some writers to signify the loss of epithelium ; 
but abrasion means a solution of continuity in the epithelium, and 
is essentially the same as ulceration. If it suits the reader better to 
call this loss of the epithelium abrasion, I have no objection to the 
term, but I believe it less a reformation in nomenclature than a dis- 
pute about non-essentials. 

I believe further that abrasion or ulceration, instead of being an 
incident resulting directly from laceration, is an essential eifect of the 
impaired nutrition of the mucous membrane, brought about by the 
hypersemic condition of the fibrous structure of the cervix. 

This is in accordance with the teachings of that eminent patholo- 
gist, the late Dr. E. R. Peaslee, in the lectures delivered to his classes, 
and published in the Medical Record for January and February, 
1876, and most of the recent writers on gynaecology. 

That ulcerations occur in the trophic forms of hypersemia, we have 
the assurance of the late Dr. Cazeaux, who found that a large num- 
ber of pregnant uteri were ulcerated. He says:* 

"According to MM. Gosseliu, Dauyau, and Costilhes, 'these ulcera- 
tions are much less frequent than I had supposed, and are met with in 
hardly more than half the cases, while I have observed them in seven- 
eighths.' In short, therefore, the fungous condition of the neck, and the 
ulcerations, of greater or less depth, which complicate this state of the 
parts near the termination of pregnancy, seem to me to be the conse- 
quence of the active or passive congestion with which the organ is 
affected." . 

So with all the active and passive congestions the integrity of the 
mucous surface of the cervix is affected, and it is the seat of ulcera- 
tion of a greater or less depth. 

I^ow then I think we must regard abrasions, "granular and cystic 
degeneration," or ulcerations of the cervix, as results of some form 
ot uterine hypersemia — trophic, congestive, or inflammatory, instead 
of standing as an etiological condition. 

While I believe the hypersemia of the pelvic organs to be the more 
frequent form of disturbing condition, I am satisfied that there are a 
great many cases of pure neurosis of the genital organs. In these 
cases the genetic element is in the nervous system, and the manifesta- 

* Pages 456-459, fifth American from seventh French edition. 



238 PATHOLOGY OF HTSTEROP ATH Y. 

tioDS are morbid exaltations of the sensibility of the parts in which 
the suffering is the greatest. There is no congestion, no inflamma- 
tion, no displacement, or other apparent deviation from the natural 
appearances of the pelvic viscera. Yet the patient has pain and sen- 
sitiveness in one or all of them, and is the subject of the most dis- 
tressing and extensive array of hystero-neuroses. In such cases, too, 
there may be no deviation from the normal condition except that of 
pain and increased sensitiveness. They are not always even dysmen- 
orrhceal cases. Although not confined to the multipara, they are 
more frecjuently found in young girls and sterile married women. 
In considering the subject of the essential pathological conditions 
giving rise to uterine symptoms, we cannot, therefore, ignore the 
neuropathic forms of ovarian and uterine affections. They are too 
numerous and too obvious to escape the attention of tlie observing 
gynaecologist. 

3Iucous Inflammation . 

As a simple affection, that of inflammation of the mucous tissue is 
quite frequent. Where they coexist, we have the increase of size, 
hardness, and irregularity of shape indicating inflammation of the 
submucous substance, combined with the evidence of mucous disease. 

Seat of Mucous Inflammation. 

The inflammation of the mucous membrane may extend to the 
whole of it, from the fundus through the cavities of the body and 
neck to the os, and then cover the whole of the vaginal portion of 
the uterus. This extent of inflammation is not very frequent, how- 
ever, and when it occurs it almost immediately succeeds parturition 
or abortion, or is produced by gonorrhceal inflammation. I have 
seen it under these circumstances oftener than any other. It almost 
alwavs causes a o-reat deal of distress and suflering;. 

Probably the most common extent of inflammation is to the mu- 
cous membrane of the cavity of the cervix, and a portion or the whole 
of the membrane covering the intralabial portion of the os. By far 
the greater number of instances that have come under my observation 
in practice were inflammation of the membrane around the os and 
inside the cavity of the cervix. I fear that this statement represents 
a fact that has not been generally apprehended by practitioners. I 
am disposed to believe that too many physicians have failed of suc- 
cess in curing their cases because they have not followed up the 
inflammation sufficientlv above the os, in the cervix, being satisfied 



ENDOCERVICITIS WITH DIMINISHED SIZE. 239 

witli curing that which was visible only, and, in consequence, leaving 
reallv the most important part of the affection untouched. 

Cavity of the Body of the Uterus. 

Inflammation limited to the cavity of the body of the uterus is not 
common, but I am quite sure that I have met with it in several in- 
stances. Some of these had been treated for inflammation of the os 
and cervix, and cured of this, but the inflammation in the cavity of 
the body was left. Others had not had any treatment for uterine 
disease, as far as I could learn. They had habitual leucorrhceal dis- 
charge of rusty-colored mucus, very much like the brickdust sputa 
of pneumonia; the os externum was very small, and the os internum 
large, as was also the cavity of the body. One j^atient did not men- 
struate, and had not for a number of years, and although married, 
did not become a mother; the disease was caused by miscarriage iu 
early life. She was thirty-four years of age. 

IJndocervicitis. 

Endocervicitis alone, or inflammation limited to the cavity of the 
cervix, is, on the other hand, an extremely common form of the dis- 
ease. Xot unfrequeutly this form of inflammation exists without 
any appearance of it in the os or external to it. When inflammation 
of the mucous membrane of the cavity of the cervix alone exists, it 
has certain effects upon the shape and other properties of the neck 
that are apt to attract our attention. Dr. Bennett describes the os as 
patent and the cavity of the neck enlarged, so as to admit the finger 
and permit the opening of it by a speculum to some extent, so that 
we may see the inside. Xow, while this is very generally the case, 
it certainly is not always so. This open condition of the os and cer- 
vix is more frequently met with near the menstrual periods than at 
any other time, and is probably always owing to the congestion of 
the vascular tissue of the cervix and about the os. 

Endocervicitis with Diminished Size. 

I have, undoubtedly, seen many cases of this endocervicitis, in 
which neither the os nor cervical cavity was in the least enlarged, 
and others, in which the os uteri was contracted much below its nat- 
ural size. The secretions of the mucous membrane are always modi- 
fied; generally they are very much increased, and often changed in 
character. They may become purulent or sanguineous, owing to the 



240 PATHOLOGY OF HYSTEROPATHY. 

grade of the inflammation and the degree of congestion. The inflam- 
mation situated external to the os, on the end of the uterus, between 
the labia or their external surface, is very common, but it is not often 
limited to this part. It is almost always combined with endocervi- 
citis. 

Certain forms of these mucous inflammations are found more fre- 
quently in certain sorts of patients. 

Endocervicitis in Virgins. 

Virgin patients seldom have inflammation external to the os uteri ; 
their disease is endocervicitis almost always; very rarely there is a 
little rim of inflammation around the os upon the end of the uterus. 

Endocervicitis in Aged Women. 

Again, in senile patients, women who have passed the climacteric 
period, and ceased to menstruate for some years, we find the inflam- 
mation in the cavity of the cervix. The os uteri in the aged is nor- 
mally small, and simply looking at it will seldom convey a correct 
idea of the state of the cervical cavity, but the introduction of the 
probe in cases of endocervicitis will give rise to very great pain. The 
endocervicitis of old women is extremely diflicult to manage, and is 
always protracted. 

External Inflammation combined with Internal in Childbearing 

Women. 

In married, childbearing women w^e find the external combined 
with the internal uterine inflammation of the mucous membrane. 
They are the kind of patients in whom most frequently the enlarge- 
ments, indurations, and fibro-cellular inflammations are observed. 
The form of disease in persons who have been married, but never 
have been pregnant, partakes to some extent of the character of that 
of the virgin and the childbearing woman. They often have exter- 
nal combined with internal mucous inflammation, but not often 
fibro-cellular. Now, what I mean by these statements is, that these 
kinds of patients are likely to have the forms of disease which I have 
ascribed to them, but there certainly are exceptions to all of them. 



CHAPTEK XY. 

ETIOLOGY OF UTEEIXE DISEASE. 

The genital apparatus of womau is in a constant state of predis- 
position to disease. The very turgid condition of these organs for so 
many days in every month is one that in appearance borders so 
closely on the pathological that in other organs it would be taken for 
one of disease^ and the symptoms are equally like those caused by 
disease. 

This similarity between menstrual hyperemia and morbid conges- 
tion is so great that it makes it impossible to distinguish the differ- 
ence by sight and touch alone. The color of the uterus is greatly in- 
creased ; it is larger, heavier, and less easily moved in the pelvis, and 
we know that it requires only a prolongation of this condition to 
constitute a state of disease. Another degree of nervous and vascu- 
lar excitement would be morbid congestion of the uterus, and all 
experience shows that cold applied to the person when the organs are 
in this condition seldom fails to add that degree of excitement, or 
that the same thing may be brought about by standing too much or 
by other unusual exertion. 

The position of these organs at the lower part of the body, much 
below the heart, having veins without valves and of weak contractile 
powers, is another cause of exceptional hyper^emia. 

Add to these the frequent erotic excitement to which they are sub- 
jected in consequence of the peculiar sexual life a woman lives, and 
we have another predisposing condition of great influence. 

By the peculiar sexual life of woman I mean a comparison of her 
life with the sexual life of other animals. 

Female animals do not cohabit night and day the year round, dur- 
ing pregnancy and nursing. The interval between the acts of sexual 
intercourse in animals is long, and comprises all the time during 
pregnancy and nursing, while women observe no time of abstinence 
except the few days occupied by the menstrual flow, labor, and the 
period of lying-in. 

Pregnancy and parturition are strongly predisposing conditions. 
In a paper read before the Chicago Gynaecological Society, and pub- 
lished in the August number, 1880, of the Chicago Medical Journal 

16 



242 ETIOLOGY OF UTERINE DISEASE. 

and Examiner, by J. H. Etheridge, A.M., M.D., Professor of Ther- 
apeutics and Medical Jurisprudence of Rush Medical College, I 
find the following table, which I think fairly represents the subject : 



Cases. 


Causes. 




Character of Cases. 




00 Gynaecological cases. 


Confinements, . 


. 50 


Hypertrophy, . 


34 


Dispensary. 


Miscarriage, . 


. 28 


Uterine catarrh, 


53 




Hard work, 


5 


Lacerated cervix, . 


9 




Unknown, 


. 17 


Prolapsus, 


2 








Metrorrhagia, 


1 




Total, 


. 100 


Eetroflexion, . 


1 



Total, . . . 100 

The long-continued and very great hypersemia of pregnancy as 
elsewhere shown causes abrasions and ulceration before labor, while 
the pressure of the uterus upon the bladder, rectum, etc., sometimes 
gives rise to permanent pelvic difficulties. 

Parturition is so generally recognized as a predisposing cause of 
disease that the greatest care is and ought to be taken to conduct 
patients through it and the post-partum condition in order to avoid 
subsequent difficulties. 

An unusual length of time is avoided in labor because of the 
damage that may arise from too long pressure by the child^s head or 
prostration of the nervous system from violent exertion. But in the 
normal labor there are many conditions that predispose to disease. 
The uterus is left large, hypersemic, and in a state of degeneration, 
with the cervix bruised, lacerated, and denuded of its mucous mem- 
brane. 

The vagina and all of its surrounding tissues have been stretched, 
pressed, and bruised, and the vulva and perinseum are torn and bleed- 
ing. While all these are conditions necessarily attendant upon a natu- 
ral process, and consequently must be regarded as normal, yet they are 
certainly upon the verge of disease, and are predisposing conditions 
prolific of disease. They predispose to acute disease, as metritis, peri- 
metritis, cystitis, vaginitis, etc., but their influence is more frequently 
observable in the chronic affections resulting from an incomplete 
recuperation from the normal accidents of labor. 

But abortion is another strongly predisposing as well as exciting 
cause to disease of the uterus. In many cases of abortion the organ 
is repaired of damages as well as after natural labor. This, how- 
ever, is an exception to the general rule. Abortion is generally fol- 
lowed by either acute or chronic disease, and sometimes both. The 
reasons for this are too obvious to require any farther consideration. 



ETIOLOGY OF UTERINE DISEASE. 243 

Other and very grave predisposing causes may be found under the 
head of puberty and change of life. 

In a state of predisposition from any of the causes above men- 
tioned, the application of cold is often productive of congestion and 
chronic inflammation of the uterus and ovaries. 

This is often proved by the results of a cold during the congestion 
just preceding menstruation or at the time of the flow, and in child- 
bed, or for some weeks afterward. 

There are other causes which act in conjunction with the predispos- 
ing conditions I have mentioned above, but are sometimes independent 
in their effects. The abuse of the organs by the practice of vicious 
habits, masturbation, excessive intercourse, etc., standing too long, 
working the sewing-machine, and the pursuit of other employments 
that keep up a stasis of blood in the pelvis. School-teachers, sales- 
women, and sewing-girls come within the influence of these causes. 

Still other causes are accidents, violence, gonorrhoea, etc. 

Gonorrhoea is a very fruitful source of chronic endocervicitis and 
endometritis. Dr. Emil Noeggerath,* of New York city, believes 
that gonorrhoea is a frequent cause of several forms of inflammation 
in the pelvic organs of women, as of the Fallopian tubes, cellular 
tissue, ovaries, and peritoneum. He finds evidence that it remains 
in a latent condition or form in the mucous membrane, and in conse- 
quence of the influence of some exciting cause is awakened into an 
acute form of disease, which probably more frequently attacks the 
pelvic peritoneum or cellular tissue. He thinks that gonorrhoea 
often persists in this chronic form in the male, and although appar- 
ently cured, the husband is capable of infecting his wife for years 
afterward. I am quite convinced that his views in this respect are 
not without foundation and deserve the serious consideration of the 
profession. If Dr. Noeggerath's teaching should be demonstrated 
by further observation it will place gonorrhoea as a latent source of 
niischief on the same footing as syphilis. However this may be I 
am quite sure that chronic endocervicitis, in which the glands of 
Naboth are the principal seat, and when the cervical canal is filled, 
with a tenacious mucus of so tough a consistency as to make it difficult 
to remove, is frequently of gonorrhosal origin. 

We cannot always trace these chronic cases to an acute attack of 
gonorrhoea, but when we can get at the facts we will generally find 

* First volume Transactions of the American Gynaecological Society. 



244 ETIOLOGY OF UTERINE DISEASE. 

that the husband has been the subject of gonorrhoea, and probably 
yet has orleet or the chronic form of that disease. 

Under the head of puberty I have pointed out many deleterious 
influences under which the girls of this country are placed, and 
which lead, primarily or secondarily, to the development of sexual 
disease in consequence of natural and social conditions which cannot 
be escaped. 



CHAPTEK XVL 

DIAGNOSIS. 

Fortunately for suffering woman, we may arrive at demonstra- 
tive knowledge of the extent, nature, and locality of diseases of the 
generative organs, and, as a consequence, treat her diseases with the 
certainty which a positive diagnosis always insures. The evident ad- 
vantages of a physical diagnosis will render it quite unnecessary for me 
to use any argument in favor of it, or to induce medical men to resort 
to it. A physical examination, howev^er, of the genital apparatus of 
females, is quite a different matter from a physical examination of 
the chest, eye, or ear, or any other organ of the body; and hence 
the necessity of approaching and conducting it under conditions ren- 
dered imperative on account of the circumstances connected with it. 
The education and natural sense of modesty, so appropriate to female 
character, and which always command the respect of gentlemen, 
make such examinations disgusting and disagreeable above almost 
all others demanded by the necessities of woman's circumstances. 
With a view to this fact, it is our duty, by our conduct toward our 
patient, and the. management of the examination, to divest it as 
nearly as possible of every disagreeable feature. Medical men gen- 
erally, I think, are, as they should be, actuated by the above consid- 
erations, and I fear that they are often so influenced by their own 
sense of delicacy as too frequently to abstain from the enforcement 
of essential investigations. This is an error we should always beai* 
in mind, and, I think, we shall less frequently regret a thorough, 
although somewhat indelicate examination, when dictated by an 
honest and intelligent conviction of Its necessity, than a neglect of 
such examination from too great a deference to a sense of shame. 
We should not. In Important cases, take things for granted. 

Our bearing to a female patient should be deferential, candid, and 
modest. She should be convinced by our demeanor that everything 
we do and say is strictly necessary and relevant to her case, and has 
its foundation in our solicitude for her welfare. Nothing, therefore, 
should be said or done but what Is called for and obviously proper. 
This sort of treatment from her medical adviser will always com- 



246 DIAGNOSIS. 

mand the confidence and earnest co-operation of an intelligent female 
patient. There should be a full and explicit understanding, when 
possible, between the physician and the patient, as- to the necessity of 
a physical examination, in what it consists, and how it is to be con- 
ducted. The good sense of the practitioner will enable him to judge 
whether he should commit the detail of explanation to the husband, 
or some other appropriate second party, or whether he impart it di- 
rectly to the patient ; all the circumstances of the case will enable 
him to determine this matter without much difficulty. After the 
preliminaries are disposed of I would insist upon conducting the ex- 
amination without exposure. It is needless in ordinary uterine 
examinations, and should be permitted only w^hen the disease is upon 
the external parts. One position and kind of preparation, so far as 
the patient is concerned, will suffice for most cases, whether we wish 
to make a manual or an instrumental examination. There is no ne- 
cessity for the patient to unclothe herself. 

Position of Patient for Examination. 

In the ordinary work of an office I think there is nothing more 
convenient than Wilson's chair. It can be made to assume so many 

Fig. 51. 




E. H. Sargent ACoT?^^ 

Wilson's Operating Chair. 

forms that it can be used as a chair or table either, and is easily 
moved into any position in relation to the light. 

For many purposes, however, a table will affi:)rd us more satisfac- 
tion. It is very much to be preferred in surgical operations. 



POSITION OF PATIENT FOR EXAMINATION. 



247 



"While the gynaecological table represented in Fig. 52 is very con- 
venient for an office, an ordinary table such as can be found in any 
dwelling can be made to answer every purpose. 

There are three positions of which we may avail ourselves in mak- 
ing examinations or performing operations, the dorsal, the latero- 
abdominal, Sims's position, and the knee-chest position. 

In the ordinary dorsal position the patient is placed on her back 
with the breech very near the end of the table or chair, the knees 
flexed and the thighs drawn up close to the abdomen, the feet resting 



Fig. 52. 




Byford's Operating Table. 

by the side of the nates or in the stirrups, and the shoulders elevated 
upon pillows. In this position both hands may be used with great 
freedom in exploring the pelvic organs. 

It is, in fact, indispensable to a perfect bimanual examination, and 
is very convenient for the use of the sound, and almost every form of 
speculum. Even Sims's speculum can be made to do eflPectual service 
in this position. 

For many minor operations and uterine applications it is a very 
convenient position. This was a favorite position with the late Pro- 
fessor Simon. When the hips and shoulders are greatly elevated, the 
knees extended, and thighs forcibly flexed upon the abdomen, this is 
called Simon's position, and is not inferior to any other for examina- 
tion or surgical operations on the vagina and uterus. 

Sims's position consists in placing the patient on her left side, with 
left arm under and behind the body, her knees drawn up close to 
the abdomen ; the right, flexed to a greater degree and overlying the 
left, rests on the table in front. The patient thus lies upon the left 
side, with the abdomen somewhat dependent. 



248 DIAGNOSIS. 

When the perlnreum is drawn back the vagina is distended by 
atmospheric pressure, and the vaginal wall and uterus brought into 
view. 

The knee-chest position is also Sims's position, and produces the 
same effect in dilating the vagina obtained by the other, only perhaps 
in an exaggerated degree. 

The patient should be placed in a good light, in order that we may 
see every part exposed by the instrument. 

Digital Examination. 

The mode of examining the pelvis with the fingers is of the utmost 
importance. After oiling the fore and middle fingers the index should 
be very 2:entlv introduced, and the examination conducted as far as 
possible with it ; then the two should be introduced, with which nearly 
all the cavity of the pelvis can be reached. The index finger will 
not reach as far, by one and a half or two inches, as the two together. 
As the finger is introduced, it naturally and easily comes in contact 
with the rectum, which may contain faeces, and consequently will 
appear as a round, full ridge along the middle line of the posterior 
wall of the pelvis, or, in the absence of these, a mere soft fibrous cord, 
hardly perceptible to the touch. By pressing upon the rectum with 
the finger, we may ascertain the presence of inflammation by the in- 
creased sensitiveness; the organ Is absolutely insensible to moderate 
pressure when in a state of health. We should seek for internal 
haemorrhoids, or the induration and contraction indicative of stricture; 
and, in short, examine it as completely as possible in this way. Next, 
we should turn our finger forward, pass it up behind the symphysis 
pubis, and along the front wall of the vagina, and as well as practi- 
cable ascertain the condition of the bladder. It may contain a calcu- 
lus,, or other foreign substance, or, what is very much more common, 
be inflamed. In the first case the foreign body may be felt by the 
finger. The examination is more complete if the fingers of the left 
hand are used to press Into the pelvis from just above the symphysis 
pubis. The substance can thus be grasped by the fingers of the op- 
posing hands. With the fingers of one hand above the bladder, and 
the other in the vagina below It, we press it and thus ascertain its 
sensitiveness. With the two fingers of the right hand pressing up 
by the side of the uterus, between it and the walls of the sides of the 
pelvis, first on one side and then the other, wdiile the fingers of the 
left hand press downward toward them from above, so as nearly as 
possible to meet them, the cavity may be pretty thoroughly explored. 



DIGITAL EXAMINATION. 



2i9 



and any unnatural substance or uncommonly sensitive tissue be easily 
discovered. All these manipulations should be performed with the 
utmost gentleness, remembering that rudeness may deceive us as to 
the sensitiveness of organs, as well as give the patient unnecessary 
suffering. But while we are gentle, we should be as thorough as 
possible. The main object, however, for which we institute these 
examinations is to ascertain the condition of the uterus with respect 
to position, size, shape, consistence, sensitiveness, etc. 

Where is, or ought to be, the os uteri and cervix, and how shall 
we find them? In the virgin, the os uteri ought to be in the middle 
of the pelvis, upon, or a little below, the level of the arch of the 



Fig. 53. 




Natural Position of the Pelvic Organs with Full Bladder, 



symphysis pubis, and witbin easy reach of the index finger, two inches 
and a half from the entrance of the vagina. AYe may know the neck 
of the uterus by its consistence, shape, size, etc. It has more con- 
sistence than any part with which our finger comes in contact, as we 
push it backward into the vagina. In passing through the vaginal 
canal, the finger is impressed with a soft, intestinal sensation, and 
can distinguish nothing but loose folds, that are dissipated and lost in 



250 



DIAGNOSIS. 



the surrounding softness bv the slightest pressure, until it comes to 
the neck of the uterus, which has consistence enough to retain its 
shape under considerable pressure. If we push it upward, backward, 
or downward, it retains the same characteristics. The finger can be 
carried up the side, up before, or behind it as a projection, and sur- 
round it in every direction except above. This being unlike any- 
thing else in the vagina, will be easily recognized bv an uneducated 
finger. The shape of the virgin cervix uteri is almost cylindrical, 
slightly compressed from before backward, and not far from three- 



FiCt. 54. 




Virgin Uterus and Vagina, 

quarters of an inch in diameter in every direction; it projects half 
an inch into the vagina, and the projecting or free end of it is ap- 
parently cut nearly square off, so as to present at its inferior face 
almost a flat surface, with a mere dimple in the centre corresponding 
with the OS uteri. 

The cervix uteri of the childbearing woman is generally a little 
lower in the pelvis, and often slightly turned to one side, does not 
project so much into the vagina, is about an inch wide, or often a 
little more, and from half an inch to three-quarters in its antero- 



OS UTERI IN THE AGED. 



251 



posterior diameter; and, instead of being truncated, seems formed of 
two distinct projections at its inferior extremity (the- anterior and 
posterior labia of the os uteri). Between the labia or projections is a 
deep fissure, with its extremities directed to the sides, large enough 
to partially admit the extremity of the index finger. Os tincce is 
applicable to this form of the os uteri, but in nowise is expressive of 
the shape of the virgin os uteri; neither is it descriptive of the senile 
uterine mouth. 

Os Uteri in the Aged. 

The OS uteri in the old is higher in the pelvis than in the virgin 
or multipara, does not project into the vagina, and feels more like a 



Fig. 55. 



Fig. 56. 





Uterus of a Childbearing Woman, 



Senile I'tenis and Vagina, 



pit at the termination of the vagina. As w^omen advance in age, this 
description is more applicable than very soon after the cessation of 
the menstrual discharge. There is often a cord or fn«num-like pro- 
jection in the vaginal w^alls, which is planted into the external sur- 
face of the anterior and posterior lips of the mouth of the uterus, and 



9n9 



DIAGNOSIS. 



thus extends backward and forward to be lost in the anterior and 
posterior median line of the walls of the vagina. This frsenum is 
more apparent, if not more developed, as women advance in age; but 
I have known it so prominent as to be mistaken for the result of 
disease, even in the middle-aged. In one case an intelligent prac- 
titioner thought it an evidence of the injurious effect of strong caustics. 
The consistence of the virgin and multipara cervix uteri is the same. 
To the sense of touch it gives the idea 'which is a correct one) of deep 
fibrous tissue, almost as hard as cartilage, covered over thickly with 
areolar tissue. Dr. Bennen compares it to the feel of the cartilage of 
the lower extremity of the nose. It seems to me not quite so dense, 
although nearly so. In health it is wholly insensible to pressure 
with the pulp of the linger, and it requires considerable force to pro- 
duce pain with a plain round instrument. This fact should be borne 
in mind in our examinations, viz., a healthy cervix uteri is not tender 
to the touch. 

Corpu^s Uteri. 

^e may examine the shape, size, and sensitiveness of the b<xly of 
the uterus by pressing it down well into the pelvis with the left hand. 
while the fore and middle fingers of the right press upon it as high 
up as possible. When the uterus is healthy, the fundus cannot gen- 
erallv be felt above the svmphvsis. even bv liftinor it with our fino-er.-. 
so that if it can be felt bv both hands it mav be considered enlarored. 

A Tender UtenMs is an Infiarned Uterus, 

A healthy uterus is insensible to the handling of an ordinary ex- 
amination, and o. tender uterus is a diseased uterus — in fact, ^enerallv 
inflamed, which condition converts comparatively insensible organs 
elsewhere — the periosteum and cartilages, for instance — into highlv 
sensitive ones. 

Examination per Bectum. 

The digital examination of the uterus would nnt be complete with- 
out an exploration of it through the rectum. The index and middle 
fingers, or the former alone, introduced its full length into the rec- 
tum will reach high up the posterior surface of the uterus, and when 
retro verted may be extended entirely above the fundus and meet the 
point of a catheter directed backward and downward through the 
bladder. They may also survey the regions of the ovaria on either 
side, and discover disease or effusion in the folds of the broad liga- 



OBJECT IN USING THE PROBE. 



253 



Fig. 57. 



Fig. 58. 




ments as well as those organs, especially when the parts are pressed 
down well into the pelvis bv the left hand from above the pubis. 

The body of the uterus is more easily reached through the rectum 
tlian the vagina, and its posterior wall 
may be, in many instances, surveyed with 
great distinctness. When the uterus is 
retro verted or retroflexed, we can often 
pass the finger through the rectum en- 
tirely over the fundus and examine the 
anterior face of the organ. AVe may thus 
determine the diagnosis between the dis- 
placement and a small fibrous tumor sit- 
uated in its posterior wall. In cases of 
anteflexion, we distinguish the point of the 
curvature of the posterior wall by the 
finger in the rectum, and thus assure our- 
selves that the tumor anterior to the os 
uteri is not a growth but the fundus turned 
forward. The width of the body of the 
uterus may be very accurately determined 
by the finger in the rectum. We may 
also get a good idea of its weight. Two, 
three, four fingers, or the whole hand, may 
be introduced into the rectum when the 
importance and obscurity of it demand. 
The introduction of the whole hand, how- 
ever, is not devoid of danger, and the oc- 
casion for it must be imperative. 

Dr. Simpson recommended and prac- 
ticed the use of the probe or sound for the 
purpose of examining the uterus, and he 
has given to it a certain appropriate shape, 
size, and adjustment, which adds very con- 
siderably to its usefulness and adaptability 
to this particular use. It may be found 
in almost any of the shops of our instru- 
ment makers, under the name of Simpson's 

uterine sound. . uterine Probe, Simpson's Sound. 

or Sound. 

Object in Using the Probe. 
The main objects in examinations with the probe in such cases as 
I have now under consideration are, to measure the size and length 



251: BIA6SOSIS. 

ci tbe ceanrical and utenne caTitMS, the mobilij^ and portion of the 
ntems, and, if need be^ the cmmedion <yf that or^an with peliric 
growd]^ The instnunent mi^ be adapted to tib^e poipoges; it 
nmslt be losf e;?^^?^^, of the ii^t aze, and made of Sexible mdtaL 

iSise and LmgOt of Pnbe. 

It dioald be ten or tweL^e inches loogg with one aid fixed to a flat 
basdle: 1^ jmibe end ^loald be terminated with the oidinaij probe- 
jirgement about one-e^itb of an inch in diameter. The 
wir^ >ri.jQNi the bolboos tennination shoold be <me fine in diameter, 
roond and anootfa,and ^loold gndoalfy increase in ^zeto the han- 
dle where it oo^t to be aboot a qfuarta* of an inch in diameter. 
The best maiima\ I think, m €»pper, ^vanized. It h alwajs well 
to haine two or duee sizes of probes fat fecial purposes, bat the one 
I have here described m the one I dboold leoommend fisr most cases. 

Thig soond wiD be foond Teij coninenknt far mdinaiy poipoees. 

Simpson's soond is hogEr, less flexibly and gradoaled, marked by 
I. : J es indkath^ inches. For measorii^ the d^di of die otems. 







Tarv to 




probe can sometimes :e i^sseed into ttr _ 

woold not enter it; in €OB3eq[DeDoe of a si. - aft^n 

adapt itself to tibe iir^olarities in Ae c . llL and 

uterine cavities. This probe is aSbsa : :f its low 

degree of flexilnlitj. Jenk^s fienble ~ r rages 

which in some cases render it soperior :: ^^v .^c^\..^ : . .;awBl 

with a less degree <^ that qoalitj. 

Dr. Thoma^s whal^Mne sound m also verjr needfhl ' 



OBJECT IN USING THE PROBE. 255 

to survey a cavity of great tortuosity. It is small, and so flexible 
and elastic that in the hands of its inventor it has been of great ser- 
vice in diagnosing intrauterine tumors. Dr. Jennison's exploring 

Fig. 61 



Cs. 


C 






A^«>?«" 


/ 


Jennison 


e, H. SARQENT & CO., 
CHICAGO. 

's Exploring and Indicating Sound. 



and indicating sound is also useful for indicating the depth and direc- 
tion of the uterine cavity. 



Fig. 62. 



Fitch's Measuring Sound. 



Accidents of serious character sometimes occur in using the probe 
in the uterus. Dr. Engleman, in the St. Louis Medical and Surgi- 
cal Journal, says that he was present when Professor Carl Braun, of 
Vienna, pushed the uterine probe through the tissues of the uterus 
into the peritoneal cavity. Dr. Noeggerath, of New York, mentions 
a case where the sound had been passed five inches, going through 
the fundus uteri, as shown by the discovery of a cicatrix at a post- 
mortem examination made several months afterwards. 

Other unquestionable instances of this accident are on record. Of 
these cases I have heard of none in which any untoward consequences 
followed what would seem to be at least a serious occurrence. As all 
the cases published were in the care of skilful and careful practi- 
tioners their occurrence must therefore be attributed to some other 
circumstance than rashness. The probability is that on account of 
disease the uterine structure had become too frail from attenuation or 
softening to resist the slight force used to introduce the probe. It is 
interesting as well as surprising that so little effect followed the vio- 
lence done by the forcible passage and entry of the probe to the uter- 
ine wall or the contents of the peritoneal cavity. 

The Fallopian tube is sometimes so patulous from disease as to per- 
mit the sound to pass through it into the cavity of the peritoneum. 
Where the whole of the uterus is enlarged, as it is found for many 
days and sometimes weeks after parturition, the uterine orifice of the 



256 



DIAGNOSIS. 



tube is large enough to admit the probe. This may be the case also 
from the enlargement caused by uterine catarrh. When the opening 
to the tube is thus enlarged it requires but a slight inclination of 
the uterus to one side of the pelvis to bring the Fallopian orifice in 
a direction to be easily entered by the instrument. When once it 
has entered the tube the probe will find no resistance to its farther 
progress. 

In a discussion before the Obstetrical Society of New York, Jan- 
uary 17th, 1871, reported in the Journal of Obstetrics of August, 

Fig, 63. 




1871, Drs. Budd, Thomas, and Noeggerath, all speak of cases in 
which the sound would seem to have entered the peritoneal cavity to 
a long distance through fhe Fallopian tube. 

Dr. Kosa Engert was kind enough to show me a case quite recently 
in which she repeatedly passed the sound through the Fallopian 
tube. When the end of the instrument had reached the fundus it 
required but little inclination to the left to cause it to enter the tube. 
The patient experienced no inconvenience from the examination. 

Another accident, and one of more importance because of its 
almost invariably fatal effects upon the embryo, and also because of 



LENGTH OF THE CERVICAL AND UTERINE CAVITIES. 257 

its more frequent occurrence, is the damage done probing an impreg- 
nated uterus. 

Too orreat caution cannot be observed in makino^ investigation of 
the condition of the uterus before passing the probe into its cavity. 
I have known two instances, however, in which the impregnated 
uterus was probed to a depth of several inches without interrupting 
gestation. AVhen a suspicion of pregnancy exists there can hardly 
be a circumstance so grave as to justify the use of the probe. 

In such cases we should unhesitatingly wait until time solves the 
question of pregnancy. 

Jlode of Using. 

After oiling the instrument, and introducing the index finger of the 
right hand, and placing it upon the os uteri, the probe may be carried 
along the palmar surface of the finger until the point arrives at the 
mouth of the uterus, when, by elevating the point, it may be carried 
forward into the cavity of the cervix. In order to insure its passage 
through the cavity of the cervix, into the cavity of the body, the 
probe must be bent to the same degree as the male catheter. Great 
gentleness must be observed in the use of this instrument, because it 
is an easy matter to do violence to the mucous membrane by a very 
little rudeness of management. After the probe has passed to the os 
internum, a sense of constriction is felt through the instrument, 
which feeling soon gives way, and the probe then goes to the fundus 
without further resistance. 

Length of the Cervical and Uterine Cavities. 

The cervical cavity in the virgin is about an inch and a quarter in 
depth, and the cavity of the body from a half to three-quarters of 
an inch ; the former in the multipara is one and a half inches, and 
the latter an inch deep. In old age both are nearly or whollj^ oblit- 
erated. I do not often use the probe in this way for the examina- 
tion of the uterus in cases of inflammation and ulceration, but have 
adopted the suggestion of Professor Miller, of Louisville, and use it 
through the speculum, and shall consequently have more to say about 
it in connection with the use of that instrument. 

It often happens, with the present means, that there is great diffi- 
culty in determining the thickness of the uterine walls, and even the 
presence of a small growth iu the anterior or posterior parietes. 
For the purpose of enabling the inexperienced to arrive at what, in 
many instances, is valuable information in this respect, I have devised 
what may be called the hysterometer, a cut of which is here given. 

17 



258 



DIAGNOSIS. 



It consists in the adaptation of two uterine probes to each other, 
with handles and scale for measurement, in such a way that one may 
be introduced into the bladder, and the other into the rectum. Thus 



riG. 64. 




The Hysterometer. 

approximated on the uterus, as represented in Fig. 65, the handles 
and scale may be so arranged as to make the measurement. When 
this is done the instrument may be detached, withdrawn, and the 
exact thickness of the uterus is ascertained. If we wish to measure 
the posterior wall, one probe is introduced into the cavity of the 
uterus, and the other into the rectum, and the scale and handles ad- 
justed, the measurement taken, and the instrument withdrawn. 
When the anterior wall is to be measured, one is introduced into the 



LENGTH OF THE CERVICAL AND UTERINE CAVITIES. 259 



uterine cavity, and the other into the Wackier. In this way, the 
leno:th of the uterus and the thickness of the walls may be easily 
measured. 

This instrument will enable us to be much more accurate in our es- 
timate of the shape of the uterus than any other means we can employ. 
The handles of the probes are adapted to each other by means of a 



Fig. 65. 





The Method of Apph-ing the Hysterometer for Measuring the Thickness of the Uterus, 

slot, running from one end to the other, in one of the handles, while 
the other is of a size to fit into this slot closely and accurately. The 
scale is made movable, and may be easily adjusted after the probe 
portions of the instrument are in their proper place. 

In cases of distortion of the cavity of the uterus, or when there is 
a tumor to measure, the probes will be bent in different directions, 
until they adapt themselves to the shape of the parts. In consequence 
of the necessity of variance in the curvature of the probes in making 
such measurements, the scale can serve only as an index to the rela- 
tive position of the two probes, and cannot be relied on for the exact 
size of any growth or other cause of thickness of the walls. After 
having adjusted the scale, therefore, and observing the figures, we 



260 



DIAGNOSIS. 



must withdraw the instrument and readjust by the scale, and then 
measure the distance between the points of the probes. This will 
give us the true measure. Often the instrument may be withdrawn 
with loosening it, which fact will facilitate the process very much. 

In cases of retroversion or retroflexion, when we wish to diagnos- 
ticate these displacements from a small tumor, which they sometimes 
very closely simulate, one of the probes in the bladder, so curved as 
to follow downward and backward the anterior wall, the other in the 
uterine cavity, will clearly make out the difference. In like manner, 
only with reversed curves, and one probe in the rectum, the tumor 
may be diagnosticated to be present or absent. 

Speculum. 

Since the speculum has come into such general use, it has assumed 

a variety of shapes, and been 
composed of quite a number of 
different sorts of materials. For 
different purposes it is conve- 
nient, if not necessary, to be 
provided with different shapes, 
sizes, etc. ; but for ordinary use 
we ought to have three dif- 
ferent sizes : one small, one 
large, and the other of medium 
size. 

The bivalve, trivalve, and Sims's speculum and its modifications 
are the most useful forms. 

Fig. 67. 




Higby's Speculum. 




Nott'i 



Nelson's, Nott's, and different sizes of Higby's. 



POSITION OF PATIENT FOR SPECULUM. 



261 



To aid us in getting a good view of the cervix, we may draw it into 
view, and, if necessary, depress it somewhat by the single or double 
tenaculum. 

Fig. 68. Fig. 69. 




Nelson's Tenaculum. 



Kelson's (open). 



Position of Patient for Speculum, 
To be prepared to use this instrument to the best advantage, our 
patient should be placed in the position I have heretofore described, 



Fig. 71. 




Double Tenaculum Forceps. 

viz., before a large window, through which as much daylight should 
be freely admitted as possible. The better light the better view, and 
unless we have plenty, we cannot be certain of correct results in our 

Fig. 72. 



Tenaculum Forceps. 

examinations. The bed and patient should be so placed that the light 
may fall straight through the instrument, and full upon the parts at 
its internal extremity. We should also have some cotton-wool, sweet 
oil, and a couple of napkins, together with the dressing forceps I 
have before spoken of. 



262 



DIAGNOSIS. 



Mode of Using the Speculum. 

In comaienciDg the examinatioD, we should oil our speculum, and 
our middle and index fingers. Kneeling before the patient, we should 
introduce the index finger, and, if need be, the middle one also, to 
ascertain the position of the cervix uteri. This precaution will enable 
us to know in what direction, and how far, to introduce the specu- 
lum. After this preliminary examination, the forefinger and thumb 
of the left hand should be placed upon the edge of the labia, one upon 
each side, with which they should be gently separated ; and holding 




the speculum in the right hand, somewhat like a pen, we may intro- 
duce it by the guidance of the thumb and finger placed as above. In 
introducing it, we should push it forward sufficiently to reach the 
cervix, and direct it upward, doAvnward, or to one side, as we may 
have ascertained, by digital examination, to be the position of the os 
and cervix. 

How to Find the Os Uteri. 

If this is not the case, we may use our probe, and gently push the 
parts from one side to the other, turning the speculum in different 
directions until it is found. If the neck is too large to enter the 
speculum, we may spread the blades still more until it is brought 
into full view. Most frequently the parts are covered with some sort 
of secretion, and we should always, with cotton-wool or lint, with the 
dressing forceps, remove all of it, so that the naked mucous membrane 



HOW TO FIND THE OS UTERI. 



263 



alone presents itself to our view. Without this precaution, we may 
overlook an obvious and extensive ulceration ; for as the parts are 
covered over with this thick, opaque secretion, it either completely 
hides them from view or much modifies their appearance. I have 
often met with cases which I have observed attentively, for the pur- 
pose, if possible, of detecting ulcerations without this step, but failed, 
until the cotton was used, when extensive ulceration appeared. In- 
deed, I never think of coming to a conclusion of any kind by the use 

Fig. 7^. 




Bj'ford's Dressing Forceps. 

of the speculum without this precautionary measure. By this means 
we can see the color, size, shape, and some other conditions of the 
parts, and the color, consistence, and derivation of the secretions. 
When the mucus, pus, or blood, comes from the mouth of the uterus, 
we can see it issuing from it. The shape and size of the neck and 
OS of the uterus difPer in different individuals, according as they have 
been impregnated or not. 

Dr. J. Marion Sims has instructed us in a different method of 
making examinations. He prefers a table. The patient is placed 

Fig. 75. 




on the left side, the left arm under and behind her, the legs strongly 
flexed upon the thighs, and these again upon the abdomen, while the 
right knee is thrown forward, and over the left one on the table; 
this turns the patient over on the chest and partly on the abdomen. 
In this position his speculum is introduced by placing the forefinger 



264 



DIAGNOSIS. 



of the right hand in the concavity of the extremity to be used, and 
the finger and instrument introduced together. When well 
inserted, the perinaeum is drawn backward and the instrument 
is given to an assistant to retain in place. This will generally 



Fig. 



Fig. 7( 



Sims' s Depressor. 



expose the cervix uteri completely ; but if it does not, the de- 
pressor is placed upon the anterior wall, and this latter is 
pressed out of the way, as represented in Fig. 83. Great 



Tenacu- 
lum. 




Dr. Emmet's Speculum. 

freedom of examination is thus obtained in most cases. Still, 
if the OS uteri is not seen plainly, it is seized with a tenacu- 
lum and drawn toward the external orifice. Many practitioners 
prefer this method of exposing the organ for all ordinary 
purposes of inspection and application. Dr. Emmet has im- 
proved upon the speculum of Dr. Sims by constructing it in 
a fashion that renders it self-retaining, and thus does away 
with the necessity of having an assistant. Many other self- 
retaining instruments have been invented, that answer an ad- 
mirable purpose, among which I mention those of Dr. Fallen, 
of St. Louis, Dr. Nott, of New York, and Dr. Thomas. Of 



Fig. 7S 



^ 



Xott's Tenaculum Forceps. 

course it is necessary to have the patient so placed that the light 



HOW TO FIND THE OS UTERI. 265 

will fall full into the dilated vagina and on the cervix. Dr. Sims 
draws the cervix down, when necessary, by means of a tenaculuai; 

Fig. so. 





Simon's Speculum, different sizes. 



this often facilitates the examination, and enables the practitioner to 
make applications or operations upon it with much certainty. 



266 



DIAGNOSIS. 



Appearance of the Os and Cervix in the Virgin. 

The virgin uteras is small ; the cervical end is nearly round, and 
terminates in a truncated extremity. Through the speculum it does 
not present the appearance of labial projections, and the os is either 
a small slit, about a quarter of an inch long, or a round opening into 
the middle of the truncated extremity. It is about large enough to 



Fig. 81. 



Fig. 82. 





Simon's Retractors. 



Lever for Dilating the Vagina from the Side. 



admit with facility the end of a female catheter, and the neck projects, 
in relief, from the bottom of the parts exposed by the speculum, 
somethino; like half an inch. 



Appearance of the 31idtiparous Uterus. 

The appearance of the multiparous uterus is quite different from 
this; the cervix terminates in labial projections, which divide its 



APPEARANCE OF THE MULTIPAROUS UTERUS — COLOR. 267 



extremities into an anterior and posterior half, and it does not pro- 
ject with so much prominence into the specuhim. The os is repre- 
sented by the cleft between these labial projections, and is large 
enough, in many instances, to admit the tip of the index finger. 



Fig. 




This figure represents the Action of the Instruments in Sims's metliod of Examining 

the Uterus. 

Ajppearance in the Aged, 
In the aged the labial projections seem to have atrophied to oblit- 
eration, and the speculum shows a round opening in a funnel-shaped 
depression, surrounded by the walls of the vagina. 

Exceptions to these Appearances. 
Although the above is an accurate description of these appearances 
under the different circumstances, there are many natural deviations 
from it. 

Color. 

The color of the mucous membrane covering the cervix, and enter- 
ing the OS uteri, may be compared to that of the inside of the lips of 
the mouth, a pale rose-red. 

Appearance of Secretion. 
The parts are merely lubricated, not smeared or inundated, with 
mucus. Tliere is just enough of this secretion to keep the membrane 



268 DIAGNOSIS. 

moist, but not enough to hide the surface from view. I speak now 
of the cervix uteri. 

Indication of Mucus in Abundance. 

An abundance of mucus must be regarded as an evidence of ex- 
citement ; its constant and persistent abundance as an evidence of 
disease. ^' Remember, that in spite of their name, it is not the busi- 
ness of mucous membi*anes to secrete mucus; the more perfect their 
condition, the more favorable the surrounding circimistances, the less 
they do so. . . . The greater the diminution of their life, the greater 
the secretion." The more disease, the greater the secretion, ootil 
their integrity is desti'oyed, when the secretion becomes modified. 
The source whence this mncos is derived will show the point of dis- 
ease ; if it comes from the os uteri, the disease is in the cavity of the 
cervix or body of the uteras. 

Indication jrom Pus. 

It is extremely doubtful whether pus can be produced by a mucous 
membrane without destruction of the epithelium at least. Temporary 
congestion often increases the amount of mucus to be found in the 
vagina, but gives origin to no pus. The color of the mucous mem- 
brane, in cases of congestion, is a livid or a dark purple-red, instead 
of the scarlet of abrasive inflammation. 

Probe and Speculum Conjointly. 

When the neck of the uterus is exposed in the speculum, it will 
often be profitable to use the probe. If proj^er attention is paid to 
appearances under the use of the probe, much information may be 
gained. When the mucous membrane of the cavity of the cervix or 
body is inflamed, it is generally much more fragile than natural, so 
that it bleeds upon slight contact with the end of the probe. In cases 
where the inflammation extends to the cavity of the uterus, the probe 
j^asses the os internum without obstruction, and passes farther up 
than natural from the increased size of the cavity. 

Dilatation. 

By properly dilating it, we may subject the cavity of the uterus to 
a digital examination. Sufficient dilatation may be efiected by the 
use of tents and dilating instruments made for the purpose. The 



DILATATION. 



269 



compressed sponge, laminaria, tupelo, and slippery elm tents are all 
employed as means of dilatation. The sponge tents, as prepared and 
sold by instrument makers, are of various sizes and lengths. They 
are, or ought to be, perforated lengthwise, carbolized, and covered 
with a lubricant to facilitate their introduction. 

The sea-tangle or laminaria and the tupelo tents should also be of 
different sizes and lengths, smoothly polished, and very slightly taper- 



FlG. S4. 




Sponge Tents. 



flexed 



ing. All of these materials are susceptible of being made in 
form to suit the curves of the uterus. When any of these tents are 
introduced in a dry state into the uterus, they absorb the moisture 
of its cavity and increase in size, and as they do so they dilate it. 



Fig, 85. 



Laminaria Tent. 



The sponge expands more rapidly than the lupelo or laminaria 
tents, and is less powerful in its dilating influence. There is not 
much difference in these respects between the tupelo and laminaria 
tents. Perhaps the latter expand more strongly and act more 
powerfully. 

As the sponge dilates, it presents a rough surface to the mucous 



270 DIAGNOSIS. 

membrane^ and to a considerable extent impairs its epithelial cover- 
ing. The surface of the tupelo and laminaria tents do not become 
rough as they expand, and consequently are not so likely to be fol- 
lowed by injury to the mucous membrane. As the laminaria becomes 
moist, it exudes a mucilage that serves as a protection to the mucous 
membrane. 

All of these tents should be well secured by having a strong thread 
attached to them. The thread should be passed through the whole 
length of the sponge and tied in a loop. This thread enables the 

Fig. 86. 



Tupelo Dilators (hollow). 

practitioner to remove the tent by simple traction, and does away 
with the necessity of the introduction of an instrument for that pur- 
pose. 

Tents intended to dilate the cervix, of whatever kind, should be 
introduced at the home of the patient, because perfect quietude in 
bed is one of the best measures to prevent the untoward effects some- 
times caused by the use of them. 

Sims's position is the most convenient for the introduction of the 
tent. In this position the cervix may be exposed by Sims's specu- 
lum, drawn slightly forward, and fixed by the uterine tenaculum or a 
small vulsellum (Fig. 87). The tent, mounted on a tent-holcler, or 
seized by the dressing forceps, is passed in until the inner end has 
entered to the os internum. The upper part of the vagina must be 
packed with cotton placed against the end of the tent, upon which it 
is made to rest. This will secure it in position, otherwise it might be 
more or less completely dislodged and thus fall short of its fullest 
effects. The first tent should be of a size that will permit it to pass 
easily into, and yet snugly fit the cervical cavity. If sponge, it will 
generally require about twelve hours to fully expand, and should the 
dilatation not be sufficient to admit the finger, the vagina and cervical 
cavity should be thoroughly cleansed with carbolized water, and a 
second sponge introduced in the same manner as the first. The 
second tent must be large enough to fill up the expanded cavity, and 



DILATATION, 



271 



secured in the same way as the first. A somewhat hunger time must 
be allowed if we use either of the other kinds, but the management 
of them is the same as that of the sponge. The wounded condition 
of the cervical mucous membrane caused by the sponge tent renders 
it very susceptible to inflammation, and calls for the strictest quiet 
and the avoidance of all co-operating morbific causes. The same 



Fig. 87 





Iklolesworth's Dilator. 



condition favors the absorption of septic material, and thus exposes 
the patient to the danger of septicsemia. This can only be avoided 
by strict cleanliness. 

In using the tupelo and laminaria tents, the main danger consists 
in the liability to produce inflammation of the uterus, which may be 
propagated to the surrounding tissue, because of their very unyield- 
ing pressure upon the submucous structures of the organ. 

From these considerations the student will learn that the use of 
tents is fraught with much danger, and should not be resorted to 
except under such circumstances as seem to render them indispensable 
to correct diagnosis and a perfect course of treatment. 



272 DIAGNOSIS. 

There are otlier means of dilating the uterine cavitj, tliat in some 
cases may be resorted to with much advantage, especially when it is 
an object to perform dilatation in a short time. 

Molesworth's dilator is one of the most simple and effective instru- 
ments for this purpose. The small-sized dilator may be made to 
enter the unimpregnated uterus, and when expanded by filling it with 
water, under strong and gradually increasing pressure of the cylinder, - 
will, in favorable instances, open the cervical cavities sufficient to 
admit the second size. 

By succeeding one size with another I have, in less than an hour, 
been able to pass my finger into the cavity of the body. The uterus 
can also be dilated rapidly by hard rubber instruments, a very con- 
venient form of which is Hank's rapid dilator. This consists of 
olive-shaped bulbs mounted on a handle. 

The smallest size may be passed into the cervix by slow and gradu- 
ally increasing pressure. It may be succeeded by the second, and 
that by the third, and so on until the cavity will admit the finger. 

When the uterus is especially hard and undilatable, the gradual 
method, consisting of the use of tents, is the proper one to employ. 
When, however, the mouth of the cervix is softer and more yielding, 
the rapid method is preferable, and in most cases Molesworth's is the 
instrument to be used. I would remind the student that great care 
is necessary to avoid damage from the use of any of these instruments 
or processes. • 

The object in dilating is to expose the uterine cavity to the sense 
of touch, and thus discover its contents and condition. Sometimes, 
with the patient in the dorsal position, we may depress the uterus, 
by placing one hand above the symphysis, sufficiently to bring its 
cavity within reach of the finger; but usually it will be necessary to 
draw it down by a tenaculum or vulsellum until the finger will pass 
up to the fundus. 

Polypoid or submucous tumors, excrescences, and cancerous ulcer- 
ation may be discovered in this way when they could not be diag- 
nosed with precision by any other method of examination. 

Characteristic Signs of Inflammation. 

The signs of inflammation of the submucous tissue or substance of 
the neck of the uterus are, increase of size, tenderness, and generally 
hardness; of the mucous membrane, increased color and secretion; of 
ulceration, still more intense redness, purulent discharge, tenderness, 
and not much enlargement. The former conditions may be ascer- 



DIAGNOSIS OF ENDOCER VICITIS. 273 

tained by tlie touch, the latter by the sight, and when they are min- 
gled, by both combined. Open external abrasion or ulceration of 
the uterine cervix, after the parts are well exposed, and cleared of 
mucus and pus by wiping, cannot be well mistaken or overlooked; 
and the practitioner must not be led to believe the case one of no 
importance because the ulceration is not very extensive. This raw 
scarlet surface is always indicative of mischief, and we should expect 
any amount of suffering from even a small patch of it. 

Diagnosis of Endocervicitis. 

There are cases where the appearances are not so obvious, where, 
in fact, all the parts exposed by the speculum and within reach of 
our vision have a natural appearance. Xo redness, rawness, or other 
discoloration can be detected on the neck, in the mouth of the uterus, 
nor on the vaginal surfaces; they are quite healthy in appearance 
and reality, but there is an obvious and, in many instances, a copi- 
ous secretion of tenacious mucus flowing from and lying in the os 
uteri; wipe this away and all looks right. This is a case of endo- 
cervicitis. In some instances this mucus is colored with streaks of 
yellow by the presence of pus, or it is wholly yellow; here there is 
loss of integrity in the epithelium of the cervical cavity. The mu- 
cous membrane in the cervical cavity is ulcerated. If we remember 
that the mucous membrane secretes only enough mucus for lubricat- 
ing purposes, in the natural condition, we can arrive at no other 
conclusion than that the membrane is in a state of hyperexcitement 
when its secretion is abundant or altered, or both. When we see 
mucus in even small, yet perceptible quantities, issuing from the 
anus, what is the inference? If this is abundant, persistent, and col- 
ored yellow, however healthy the anus might appear externally, we 
could not believe that the rectum was in a healthy condition. Why 
not then positively determine that the mucous membrane is inflamed, 
which floods the os uteri with mucus or pus, or with both ? If we 
introduce the probe into the cavity of the cervix thus abundantly 
secreting, the patient will nearly always complain that we touch a 
"sore place, a tender spot," that it hurts her in her back, etc. And 
very often blood will immediately follow the withdrawal of the in- 
strument. This, however is not invariably the case. Another diag- 
nostic evidence of endocervicitis is the increase of the pain ordinarily 
experienced by the patient when the probe or nitrate of silver is 
introduced. 

The hypersecretion, or perverted secretion of the mucous mem- 

18 



274 DIAGNOSIS. 

brane, must then be regarded as an indication of disease of that 
membrane. If we have these facts fixed in our mind, and if we act 
upon them, Vv'e may discover and cure disease that would otherwise 
escape our attention and thwart our skill. But there is another ob- 
vious and common-sense sign of inflammation which has not been 
applied in our investigations of diseases of the uterus, viz., tender- 
ness. Tenderness or sensitiveness to the touch anywhere else leads 
us to susj^ect inflammation, but in the uterus it is unaccountably set 
down as indicating an irritable uterus and not an inflamed one. 

Diagnosis of Submucous Inflammation. 

I think when I touch the uterus with the finger or an instrument, 
and the patient shrinks from the contact and says " she is sore,^' or 
"it is sore," that there is inflammation there. Tenderness is not an 
evidence of mucous inflammation, but of submucous or fibrous in- 
flammation of the uterus. 

Complication of 3Iucous with Submucous Inflammation. 

The uterus should be examined by the same diagnostic rules that 
govern our investigations of disease in other organs. Some authors 
tell us that ulceration results from inflammation of the submucous 
tissue, and others that the inflammation begins in the mucous mem- 
brane. However this ^may be, I am sure that inflammation some- 
times exists in both these tissues at the same time. In this case we 
shall have tenderness and hypersecretion. At other times there is 
submucous without mucous inflammation; then we shall have ten- 
derness without hypersecretion. Again, we may have mucous with- 
out submucous inflammation, when hypersecretion without tender- 
ness will indicate it. These remarks will fix the importance of these 
two symptoms as indicating the seat of the disease. 

Size of tJie Uterus ordinarily Increased — Exceptions. 

The size of the organ is one indication of the presence or absence 
of inflammation; but this may vary very much under what would 
appear to be the same form of disease. In endocervicitis it is usual 
to find the cervical canal increased in calibre ; but this is certainly 
not always the case, as I have met with unmistakable instances in 
Avhich this cavity was decreased in size and the os uteri almost closed, 
it being so small as to admit only a very small probe. Where there 
is mucous inflammation of the cervix extending toward the cavity of 



ATROPHY AS THE RESULT OF INFLAMMATION. 



'llO 



the body, and more particularly where the disease extends into the 
cavity of the body, the whole organ is likely to be enlarged. So 
much enlargement sometimes takes place that the fundus may be felt 
considerably above the pubis. Xeither is this always the case, how- 
ever; often there is no enlargement. The hypertrophy, or general 
enlargement of the organ, is more frequently indicative of mucous 
than submucous or fibrous inflammation. 

Atrophy as the Result of Inflammation. 

In fact, I think that long-continued inflammation of the substance 
of the body and cervix often brings about atrophy or shrinking of 
the uterus. Permanent increase of size or hardness of the cervix 
must be the result of submucous inflammation, and generally co- 
exists with it. 

Almost the only disease with which chronic inflammation and 
ulceration of the cervix uteri are likely to be confounded, is cancer 
in some of its stages. The many well-marked symptoms and physi- 
cal conditions which accompany this last disease are now, however, 
so well understood and so thoroughly described, that the novice need 
not be embarrassed in his diagnosis of it. 

I find in BecquerePs Traite Clinique des Maladies de Uterus, pp. 
320-323, vol. i, so complete and faithful a diagnostic summary be- 
tween cancer and the diflerent conditions of chronic inflammation of 
the cervix, that I have translated and given its substance for the con- 
cluding portion of this chapter. It is subjoined : 



Cancer in the Scirrhous Condition. 
Cervix hard, unequal, nodulated ; os not 

always open, sometimes wrinkled or 

furrowed. 
Scirrbus of the neck often implicates the 

vagina. 

Hereditary influence is often traceable. 

Touch is painless. 

Discharge sometimes absent ; in certain 
cases very abundant, and consisting, 
for the most part, of albuminous serum. 

Menstruation increased, being neither 
more nor less painful, and passing 
often into the state of real haemor- 
rhage. 

Absence of special anaemia when the 
vagina and body of the uterus are in- 
volved. Cancerous cachexia. 



Inflammation and Ulceration. 
Xeck less hard, developed regularly in 
one of the lips; os always open. 

The induration of the neck never ex- 
tends to the vagina. Mobility of uterus 
complete. 

Xo hereditary influence. 

Touch painful. 

Discharge constant, and characterized by 
the presence of transparent mucus, 
muco-pus, or purulent mucus. 

Menstruation more painful, often re- 
tarded, almost always scantv. 



Special ansemia, as above described. 



276 



DIAGNOSIS. 



Cancer in the Scirrhous Condition. 

Progress continuous and without cessa- 
tion. 

The pain in cancer is very sharp, in- 
tense, and hmcinating, and not influ- 
enced by locomotion or movements of 
any kind. 

Ulcerated State. 

Developed at the critical period of life 
generally. 

Preceded and accompanied by h?emor- 
rhages. 

Severe, sharp, lancinating pain. 

Development essentially in sharp ir- 
regularities and nodosities. 

Adhesions to other organs as soon as ul- 
ceration is formed ; immobility of the 
uterus. 

The surface only slightly soft ; subjacent 
tissue scirrhous. 

Ulceration deep, unequal, essentially ir- 
regular, with thick, elevated, and hard 
edges. 

Always granulations. 

Discharges extremely abundant, consist- 
ing of purulent and often sanguineous 
serum ; nauseous and often fetid odor. 

Great haemorrhage from tiine to time, 
not necessarily at menstrual period. 



Cancerous Ulceration. 
Developed upon a hypertrophied and 
scirrhous surface. 

Ulceration deep, vast, unequal grayish 
surface, with thick edges, and easily 
bleeding. 

Ulcerated surface hard, presenting nu- 
merous lobes and tubercles, with nodos- 
ities and great hardness. 

Often great loss of substance. 

Cervix and corpus uteri immovable, on 
account of adhesions. 

Discharges sanious, fetid, sanguinolent, 
and of an insupportable and charac- 
teristic odor. 

Cancerous cachexia always present. 



Inflammation and Ulceration. 
Often stationary for a long time. 

Pains less severe, more dull, and percep- 
tibly influenced by walking and other 
sorts of motion. 

Chronic Inflammation and Softening. 
Occurs earlier in life almost always. 

2sot preceded by haemorrhage. 

Pain dull and profound. 

Enlargement regular and rounded, or 

regularly lobulated. 
Complete absence of adhesions to other 

organs. Entire mobility of the neck 

and body of the uterus. 
Tissue of the cervix not hard, and easily 

destroyed. 
When ulcerations exist, less deep, with 

tumefied edges. 

Granulation often accompanies the other 
lesions. 

Discharges less abundant, consisting of 
muco-pus alone, or accompanied with 
a little blood, without odor. 

Always haemorrhage, but often a mere 
prolongation of the menstrual dis- 
charge. 

Simple Ulceration. 

Ulceration often on a healthy tissue, or 
presenting the soft or hard varieties or 
inflammatory injection. 

Ulceration more superficial, the edges 
less developed, and more regular at 
the bottom, not always easily made to 
bleed. 

Nothing of the sort in chronic inflamma- 
tion and ulceration. 

Ulceration is not always accompanied 

with loss of substance. 
Neck and body always movable. 

Discharge of muco-pus, or purulent mucus, 
always more or less abundant. 

Special anaemia. 



ATROPHY AS THE RESULT OF INFLAMMATION. 



277 



"Professor Otto Spielberg, speaking of the difficulty of distinguishing 
between simple inflammatory induration of the cervix uteri — hyper- 
plasia — and carcinomatous infiltration, gives the following as a certain 
indication of cancerous infiltration, viz. : 'A peculiar induration of the 
cervix, the disposition of its mucous membrane, and its reaction to the dila- 
tation of sponge tents' He expounds each member of this rule. 

"The hardness of cancerous deposit, in comparison with simple in- 
duration, is well known ; but the distinction is frequently impossible to 
make out, even by the most cultivated touch. The two other symptoms 
are unequivocal, and are as follows : 

" 'First, the mucous membrane in cancerous growth is firmly connected 
with the underlying induration, and immovable over it, which is not the 
case in mere hyperplastic thickening and induration ; and, second, while 
the latter, under the pressure of compressed sponge, in the cervical canal, 
becomes regularly even, though at times inconsiderably looser, softer, 
and thinner, the cancerous infiltration remains unalterably hard and 
rigid, and cannot be stretched.' He goes on to explain the reason for 
this difference between the products of the two inflammations from the 
locality where the cancerous inflammation originates, which is the utero- 
malpighii ; or, in extremely rare cases, from the glands of the cervical 
canal. The latter form gives rise to the alveolar or colloid form, of 
which he has only seen one case. As a rule, the disease is developed 
from the interpapillary depressions of the epithelium. According as the 
growth of the epithelium into the tissues below is or is not attended by 
a simultaneous growth of the papillae, two forms of cancer may be dis- 
tinguished, — the papillary velous, or cauliflower excrescence, and the 
simple infiltrated form." — Cincinnati Clinio (from Archiv fur Gynce- 
kologie). 



CHAPTER XVII. 

GENERAL TEEATMENT OF UTEEINE DISEASE. 

General Treatment 

I AM sensible of the great difficulty of properly estimating the 
value of any given remedy or plan of treatment for the cure of dis- 
ease. Xature does very much sometimes to aid imperfect means, and 
even to effect a cure under improper treatment, and very often we 
record cures and attribute great efficacy to our plan of management, 
when the favorable termination is due alone, and perhaps in spite of 
us, to the natural conservative energy of the system or the parts con- 
cerned; while at other times the circumstances inseparable from a 
case thoroughly thwart the best-directed efforts. It is often a mis- 
take, therefore, to be too sanguine in our expectations even with the 
use of a favorite course of treatment, or to depreciate everything 
which has not fulfilled our hopes. We should patiently, honestly, 
thoroughly, and judiciously try every means within our knowledge 
for the benefit of our patient, let him labor under whatever disease 
he may. The reader is, doubtless, perfectly aware of the very great 
differences of opinion in the profession as to the treatment most bene- 
ficial in inflammation of the cervix uteri and its accompanying ail- 
ments. In alluding to these many and diverse opinions, I must 
record my conviction of the honesty with which they are maintained 
by the principal disputants of the present day, and must exhort the 
junior members of the profession to cautious and thorough research 
on the subject. There must be a right and a wrong side to every 
disputed question; and, as a general thing, extremists are wrong. 
Remembering this general truth, we cannot always be kept in doubt 
by the facts in the case, if, without prejudice or party bias of any 
kind, we earnestly set to work to learn. 

Spontaneous Cures. 

Are there any spontaneous cures in these cases? I think there 
are, and I propose inquiring into the method adopted by nature, and 
take it as a guide to some extent, at least, for the plan of artificial 
treatment. Change of circumstances frequently makes robust per- 



L^ 



SUPERVENTION OF ACUTE INFLAMiM ATION. 279 

sons of invalids. This change is generally from irregular, improper 
habits of living to such as are regular and appropriate; from the 
highest state of luxury and ease to one of need, or, at least, economy 
and industry, in which the patient must exercise her mind and mus- 
cles to a proper degree. The healthy tone of the stomach, muscles, 
and brain, thus brought about, decreases the susceptibility to slight 
suffering, enables the patient, apparently, entirely to recover from 
disease, and bear small ills without complaint. I need not specify 
the various circumstances and conditions of life which improve the 
tone and elevate the functional activity of the whole organism; they 
are numerous, and will suggest themselves to the reader. How many 
journeys are taken, how much time spent at watering-places and 
places of amusement for this purpose? And often they answer the 
purpose, and the patient is restored to health. 

Change of General Circumstances only Temporary in its Effect. 

This improvement in cases of disease of the uterus is brought about 
rather by diminishing the nervous susceptibility to the wearing in- 
fluence and pain of the local disease, and by fortifying the system 
against its advance by establishing excellent general health, than by 
actual cure of the local inflammation. As a consequence we find a 
return to the former mode of living, habits, and circumstances, re- 
produces, more or less rapidly, the same train of general symptoms, 
and makes it necessary to resort to a repetition of the journey, or 
whatever other means were previously successful for their removal. 
This is only an apparent, not a real cure, and is the kind which 
always results from an exclusive general treatment. Tonics, laxa- 
tives, and alteratives put the general condition of the patient on a 
better footing, and she suffers less from her local disease, and even 
considers herself well; but if we suspend" the general roborant appli- 
ances, the patient again sinks into her former state of valetudinarian- 
ism. I have often witnessed these changes as the effect of accidental 
mutation in the condition of the patient, intentional changes of place 
and circumstances, or Avell-advised general treatment. 

Supervention of Acute Inflammation, 

There is, however, another method resorted to by nature, which 
sometimes results in a permanent and complete cure. Chronic in- 
flammation has very little tendency to spontaneous subsidence ; its 
duration is at least indefinite. Situated in the neck of the uterus, 



280 GENERAL TREATMENT OF UTERINE DISEASE. 

this is particularly the case. Acute inflammation, however, on the 
contrary, has a strong; tendeucv to terminate in resolution, to subside 
and leave the parts in a healthy condition. And, in cases of chronic 
inflammation in any of the organs, the supervention of the acute form 
proves sometimes salutary. It absorbs the whole chronic action and 
takes its place in the tissues ; and as it subsides, the diseased organ 
is left in a healthy condition. AYe have an opportunity of seeing 
this process of usurpation, displacement, or whatever else it may be 
termed, in diseases of the eye, and witnessing the salutary sequence. 

Acute Tiiflammation after Parturition or Abortion sometimes worJcs a 

Cure. 

Some of the functions of the uterus when naturally performed are 
followeil by acute inflammation in the neck of the organ. I allude 
particularly to parturition ; and while these inflammations sometimes 
linger and become themselves chronic, they generally, under favora- 
ble circumstances, subside kindly, and where the cervix had pre- 
viously been afPected by chronic inflammation, sometimes favorably 
modify if not entirely cure it. I think that very few cases of par- 
turition occur that do not cause sufficient violence to the cervix and 
OS uteri to be followed by a greater or less degree of acute inflam- 
mation. A great many are certainly thus followed. The acute in- 
flammation resulting from abortions occasionally has the same eifect. 
Instances have occurred in the hands of the most experienced prac- 
titioners, where, the uterine health of a primipara has been benefited 
by pregnancy and the processes of parturition. 

Posture, Exercise, and Pepose. 

The young practitioner will soon learn that posture and exercise 
are important considerations in the general treatment, and he will be 
taught by most writers that the reclining posture and strict Cjuietude 
must almost universallv be observed. AValkino; frenerallv causes an 
increase of pain, and, it is natural to suppose, an increase of inflam- 
mation; so that exercise on foot or in the erect position is regarded 
as injurious. On the other hand, confinement to the recumbent pos- 
ture and the observance of strict quietude is very hard upon the 
general health ; the patient becomes more nervous, and all her func- 
tions are performed in an irregular and imperfect manner. As a 
consequence, in very many instances, the symptoms are much aggra- 
vated. In the great majority of these cases, therefore, I think the 



POSTURE, EXERCISE, AND REPOSE. 281 

patients are injured by confinement and recumbency. It would 
neither be scientific, sensible, nor successful, however, to lay down 
any absolute rule in respect to exercise and quietude. I think we 
may arrive at pretty accurate conclusions as to the sort of cases and 
the conditions under which each should be observed. More than 
ordinary acuteness of the symptoms, indicating a high degree of in- 
flammation, occurring in the beginning and continuing throughout, 
or arising during the progress of a case, as the effect of tempo- 
rary causes, will make rest indispensable to the removal of them. 
Haemorrhage at the time of menstruation or between the menstrual 
periods is also a reason for strict quiet. Where neither of these 
conditions are presented, I think the patient will be much benefited 
by judiciously directed exercise. I feel like insisting upon the en- 
forcement of outdoor exercise as a rule in these cases ; for I have 
often had an opportunity of contrasting, in the same cases, the influ- 
ence of quiet and exercise upon the recovery of patients of delicate 
nervous constitutions. One patient w^ho had been unable to sit up 
for even a short part of the day for several months, on account of 
the pain in the hips, dragging in the loins, and great nervous pros- 
tration, was sent to a water-cure, and in three months she returned 
home capable of walking several miles a day, and enjoyed compara- 
tively robust health. In a few weeks after returning to a home in 
which she enjoyed the luxuries and ease so desired by all who prize 
good living, she became ^^ miserable,^^ and was obliged to abandon 
her exercise entirely. It is encourao^ino; to state, that in less than 
six months of proper local treatment, she was permanently cured. 
This is but a type of many similar cases that have been benefited by 
the enforcement of exercise and other items of proper living, but, I 
must also add, not cured. It has been my constant, aim for many 
years to induce patients of this kind to take as much exercise as they 
can bear. Under the mistaken notion that any local pain indicates 
an aggravation of their disease, and that to exercise when it gives 
them pain, even to a moderate amount, is a great evil, they confine 
themselves to their room, and even their bed, to the forfeiture of that 
healthy tone and energy of the nervous system which shield them 
from the intolerable and inexpressible ennui, melancholy, and irri- 
tability, which are so characteristic of bedridden women. Pain 
and weariness, that subside after a few hours' rest, should not be re- 
garded ; it is only in those cases in which the pain and weariness in- 
crease at every effort at exertion that exercise should be abandoned, 
and then we should insist upon its being resumed again as soon as 



282 GENERAL TREATMENT OF UTERINE DISEASE. 

sufficient advance in the cure has been made to justify another 
atte?npt. We should not tire, during the whole treatment, in our 
endeavors to institute a system of regular and gradually increasing 
exercise, on account of the consideration that it is indispensable to 
the enjoyment of useful and comfortable health. Selection of the 
kind of exercise will depend, of course, upon the condition of the 
patient in respect to pecuniary matters as well as the state of her dis- 
ease. Fortunately, the best kind is such as is within the reach of 
every kind of patients, not excepting those who are under the neces- 
sity of earning a living. The capacities and demands of our nature 
are formed to answer the curse pronounced against Adam. We not 
only earn our bread by the sweat of our brow, but the labor neces- 
sary to procure the bread brings almost all the conditions that insure 
health and happiness. It is, in fact, a great evil of the present state 
of society that our ladies cannot find in useful employment that 
healthy exercise for the body and mind which they need, and that 
such exercise and employment are allowable and acceptable only in 
amusement. There is almost no variety in mental and corporeal ex- 
ercise required by the highest social amusements, and it is only when 
we descend to the primitive sports that our demands in this respect 
are met. It is undignified in ladies to fish, hunt in the woods, or 
engage in muscular feats. They must for muscular exercise engage 
in the measured sameness of the quadrille, or the giddy whirl and 
violence of the waltz, or cramp their limbs to the steady routine of a 
system of calisthenics. What are all these, for variety and adapted- 
nes§ to their wants, compared to the washing, ironing, sweeping, 
milking, churning, spinning, weaving, cooking, walking, running, of 
household engagements, the stimulus of need ; thinking of all these 
things ; timing them ; proportioning them ; calculating, economizing, 
nursing, doctoring, advising, correcting, teaching, and conducting 
little minds and bodies through the physical, moral, and intellectual 
discipline which capacitates, unfolds, and imbues them with what is 
good and useful ? Woman's duties, taking them altogether, when 
well and appropriately performed, will do more than all the amuse- 
ments that can be invented to keep woman well and healthy in every 
particular. In fact, it is only woman thus employed that can enjoy 
amusements. To the woman that constantly seeks after amusements, 
these very amusements become an irksome and toilsome business ; 
they have a disagreeable sameness, and do not divert her; they 
simply vitiate her tastes. We all want variety, and constant employ- 



SEXUAL INTERCOURSE. 283 

ment, with a sense of usefulness attached to it. With this view of 
the usefiihiess of mental and bodily labor, I encourage my patients to 
engage in their domestic duties and labor, gauging the amount of 
labor by their capacity of endurance. Attention to the homes of 
wealthy women, as society is now constituted, requires a great deal of 
anxiety and mental exercise. Without a proper variety of muscular 
exercise, the woman, in attending to the duties connected with it, be- 
comes more nervous ; but the home of the poor industrious citizen or 
farmer gives enough, and a healthy variety, of both muscular and 
mental exercise to promote health and happiness. Should there be 
such objection in any shape as to make this course impracticable or 
improper, it is an interesting question to decide what sort of physical 
exercise is most desirable and beneficial. I am decidedly in favor of 
exercise on foot, outdoors, as one of the very best kind, far prefera- 
ble to carriage or horseback riding. Carriage riding is not sufficient 
exercise for the most of such patients, and yet those who are most 
debilitated, and utterly unable to walk, may be much benefited by 
riding in an open carriage until they become vigorous enough to walk, 
when it should be abandoned. Convalescent patients may ride on 
horseback if they can have an easy-going animal ; but this sort of mo- 
tion is too violent ; there is too much jolting for such cases until nearly 
or quite cured of the local trouble. We ought to induce our patient to 
walk more each day than the previous one, if possible, until she has 
plenty of exercise. 

Sexual Intercourse. 

Young physicians have often asked me whether sexual intercourse 
is injurious during the time of treatment, and whether it should be 
permitted? I have no hesitation in insisting upon entire abstinence 
from this act. The recovery of our patient will be more rapid, cer- 
tain, and complete when this is observed, and I believe that failures 
are the result of carelessness in this respect. It is very common for 
our patients to enjoy more comfort when absent from their husbands, 
and come home from a journey, as they think, entirely cured, to be 
assured of the contrary by the first effort at coition, and become mis- 
erable with pain, nervousness, etc., in a short time on account of in- 
dulging in this conjugal act. I desire, therefore, to be explicit in 
warning my young friends in the profession not to omit the inter- 
diction of sexual intercourse, however delicate the task. A private 
interview should be sought with the husband for that special purpose. 



284 GENERAL TREATMENT OF UTERINE DISEASE. 

3Iain Objects of General Treatment. 

The main object to be gained by general treatment is to palliate 
the general condition of the system, to aid the local in effecting the 
cure, and to remove, when practicable, the effects left after a cure of 
the local disease. A cure of local chronic disease, by general treat- 
ment alone, is hardly to be expected, although, in some instances, it 
may be indispensable to such a result. When general treatment is 
used as a palliative or adjunct in local diseases, it is directed to the 
relief of general symptoms attendant upon them. It will be impos- 
sible for me to notice the treatment necessary in all the symptoms 
which attend and add to the distress of our patients In uterine dis- 
eases, but there are certain prominent and troublesome ones on which 
I cannot with propriety omit to dwell. I do so the more readily 
from the embarrassiiftent which I know, from experience, fills the 
mind of the inexperienced as to the proper value to place upon gen- 
eral treatment and the course to be pursued. 

Many of the patients laboring under chronic uterine disease come 
to us broken down, the subject of a multitude of symptoms resulting 
from inanition and depraved functions. These prostrated patients, 
it will be found, have passed through the primary sympathetic suffer- 
ing I have elsewhere described, and are in the midst of that condition 
we have been in the habit of calling nervous prostration, in which 
general treatment becomes a very important, if not an essential, means 
of success. This general treatment consists in the correction of the 
condition of the organs which were first sympathetically deranged, — 
the stomach and its associate organs, — introducing Into the system 
nutritive material enough to relieve the anaemic state of the nervous 
centres, and conducting the patient back to her long-lost habits of 
activity. I have elsewhere expressed the opinion that the primary 
morbid condition of these organs is functional derangement, and, 
perhaps, always deficiency of their secretions. One of the first and 
most important things to be done Is to correct this derangement, and 
the two medicines that have occurred to me to be the most efficient 
are mercury and nitro-muriatic acid. Mercury has always, and very 
deservedly, had the reputation of exciting the glands connected with 
the alimentary canal, viz., the salivary, gastric, duodenal, — liver and 
pancreas, — and those of the large Intestine. Administered in small 
doses, this excitement does not transcend the limits compatible with 
health ; but given In larger doses, it produces inflammatory excite- 
ment in all of them. We can very properly avail ourselves of this 



MAIN OBJECTS OF GENERAL TREATMENT. 285 

quality of mercury in such a manner as to increase the action of all 
these glands, and thus promote the appetite and digestion and assimi- 
lation. It is, in this way, an efficient tonic, increasing the red blood- 
corpuscles and establishing a plastic habit so desirable in chronic 
diseases. To these broken-down patients I am in the habit of ad- 
ministering it in the form of blue mass or the bichloride; of the 
former one-fourth of a grain four times a day, or one grain at bed- 
time. When I give the bichloride, I generally dissolve it in the 
compound tincture of cinchona, one-sixteenth of a grain of the mer- 
cury in a tablespoonful of the tincture three times a day, after meals. 
These doses are too small for some patients and too large for others. 
When not large enough, they are not attended wdth any appreciable 
results, in which case a slight increase will be necessary. When the 
dose is too large, it usually causes diarrhoea. When it produces this 
last effect, it should be withdrawn and the acid substituted, which 
should be given in very small doses. 

Dr. L. F. W^arner, of Boston, wrote an article in advocacy of the 
use of mercury in the treatment of uterine disease for the obstetrical 
section of the American Medical Association. It was published in 
the Transactions of 1878. Dr. Warner brings forward cases to show 
the efficacy of this drug, and the article will repay perusal. 

It should be remembered, however, that medicines are but prompt- 
ers to nutrition, and that to reinstate the lost vigor the patient must be 
fed. Her anorexia should be no excuse for starvation ; food should be 
taken in sufficient quantities to nourish her, with as much persistence 
and regularity as she takes her medicine. If we wait for an appe- 
tite, starvation will go on ; and if we wait until digestion is com- 
fortable, we may often wait until inanition establishes tuberculosis, 
leucocythsemia, or some other equally fatal disease. 

AVe ought to prescribe and particularize what, in our judgment, is 
necessary, and insist upon its being taken. About the only reason 
for withholding any article of diet indicated is the rejection of it. 
Digestion is likely to be attended with discomfort of some kind, such 
as fulness, cardialgia, pyrosis, etc. ; but as the blood becomes better, 
by virtue of its tonic influence upon the organs, the secretions in the- 
stomach will improve, its muscular coats become stronger, bile be- 
comes normal in quantity and quality, and the digestion will be com- 
plete, easy, and comfortable, and the patient will regain her strength. 

The articles of diet which can be tolerated will not always be the 
same. When I say tolerated, I do not mean desired and digested 
with comfort, but I mean such as will not be rejected from the stom- 



286 GENERAL TREATMENT OF UTERINE DISEASE. 

ach, for if they are not vomited np, and do not cause diarrhoea, they 
will be digested, and hence be the source of nutrition. 

As concentrated food and generally the most nourishing, are the 
different kinds of animal food ; beefsteak, roast beef, mutton chops, 
roast or boiled mutton, milk and eggs, butter, etc., constitute a good 
assortment from which to choose and prescribe. 

In prescribing meat in any form, we will generally be met with 
the objection: "I do not eat meat; I do not care for meat; I have 
no appetite for it.'^ I sometimes think, as medical men, we ought 
to reject the word appetite from our vocabulary. These patients 
usually have no appetite, and for that very reason are starved. If 
we do not prescribe the very articles we want them to take, the exact 
quantity and the time for taking them, they will generally disregard 
our directions. AYe may tell them to take two ounces of beefsteak 
or mutton chop for breakfast, the same quantity for supper, four 
ounces for dinner, with bread and butter, vegetables, and every such 
other thing as they wish, but always the meat. Then if we prescribe 
one pint of milk after each meal, and one at bedtime, the patient will 
have a good strong diet, and it will soon be apparent in her improved 
condition. The nurse should be responsible for the taking of this 
prescription as she is for the administration of medicines. 

Some patients cannot chew their meat, but can swallow and digest 
it if it is minced finely. It will digest in this form usually very per- 
fectly. 

General Symptoms requiring Special Attention. 

The symptoms, the treatment of which I propose to speak of in 
detail, are: 1st, general nervous prostration; 2dly, nervous excita- 
bility, exaltation of nervous excitement; 3dly, anaemia; 4thly, gen- 
eral plethora; 5thly, local plethora; 6thly, constipation; 7thly, in- 
digestion. These are generally more or less complicated with each 
other, and sometimes several of them coexist; but, ordinarily, some 
one assumes the most prominence, and occasions most distress, and 
consequently requires more of our attention than the others. 

Nervous Prostration. 

There is often great nervous prostration, and a sense of weakness, 
when, so far as we can judge, hiematosis and nutrition are usually 
well performed. The cause of this depression must be sought out 
in each case, as there is no uniformity in the functional deviations. 
Very frequently there is a deficiency of menstrual discharge, the 



NERVOUS PROSTRATION. 287 

scantiness being very obvious; at other times it is too copious. We 
should inquire into the functions of all the important organs, and 
correct them, when disordered, as nearly as possible, by changing the 
habits and circumstances of the patient, and afterward, or in connec- 
tion, address remedies to the organs themselves. The stomach, liver, 
bowels, skin, kidneys, and uterus should furnish their discharges in 
the most natural manner, and if they are not doing so, should be 
corrected by the most gentle means. If several of these organs are 
in a state of functional deviation from health, we should not expect 
to correct them all at one time, but alternate our attention between 
them; first, with our remedies influencing one, and then another. I 
insist here, with reference to the plan to be pursued, that we should 
not address all these organs, or even a large part of them, with me- 
dicinal agents at one time. There is no question, I think, that com- 
plicated formulse often nullify themselves by containing ingredients 
intended for the liver, kidneys, and skin, which ought all to act about 
the same time. We should act upon each of these alternately, in 
quick succession, if we think best; but let each organ feel the full 
impression of its remedy before the blood and nervous energies are 
directed to another. In addition to this indirect way of increasing 
the tone of the nervous system, it is natural for us to look about for 
something that will act more directly. Our patient becomes so de- 
pressed, and suffers so much from terrible feelings of prostration, that 
her condition appeals to our sympathies for a more direct and imme- 
diate relief. If left to themselves, or the advice of injudicious friends, 
they almost always resort to stimulants, as whiskey, ether, chloro- 
form, ammonia, etc. In some cases only are these temporary reme- 
dies advisable, and when used, they nearly always leave the patient 
in a worse condition than before they were taken. They are allow- 
able only as necessary evils, and should be avoided when possible. 
These patients are usually depressed mentally, also, and much good 
may be done by operating upon their minds. A physician who enters 
the room with a cheerful countenance, and a pleasant and gentle 
bearing toward the patient, and who engages her in conversation, 
first about her case, and afterward about some favorite theme, will 
do more toward temporarily relieving the great nervous and mental 
depression than all the ether and ammonia the stomach can be made 
to bear. Earnest and kind assurances that her symptoms, though 
causing her a great deal of suffering, are not of a serious nature, and 
will soon subside, act generally as a good cordial to the spirit and 
nerves. In paroxysms of excessive nervous prostration, despondency, 



288 GENERAL TREATMENT OF UTERINE DISEASE. 

etc., I have seen the tonic influence of very cold air do a great deal 
toward relieving thera. These paroxysms generally occur in close 
and overheated rooms, two conditions which should be removed. If 
it is cold weather, we should cover the patient to protect her, and let 
the frosty air — the colder the better — into the room, by opening all 
the windows and doors, and keep the room cleared of visitors. It 
will astonish anybody who has not observed the effect of a tempera- 
ture near to zero on those swooning hypochondriacs. A change 
almost immediately occurs for the better. If the air is not cold, it 
will still do much good to give it perfectly fresh to the patients in 
abundance. "When able, they may be taken outdoors. This treat- 
ment introduces the natural stimulants, oxygen and cold, into the 
lungs, and brings them in contact with the nerves, and is more en- 
livening than medicine. How long the room should be kept open 
and cold will depend upon the effect, but we should always, if pos- 
sible, make these patients sleep in open, cold rooms. This is a very 
important item, which it will often require ingenuity as well as 
authority to enforce. These patients should live outdoors as nearly 
as possible, and be as much as they can on their fe^t. 

Food. 

Their food should have reference to the condition of the abdom- 
inal functions entirely, and be regulated by them. There is gener- 
ally great intestinal torpor, which should be removed if possible. "^ 
Good, cheerful company, travel, — if the patient will not employ her 
body and mind in domestic pursuits, — temperate and reasonable di- 
versions, and, above all, time and patience, are requisite remedies. 
The affection is obstinate and chronic, and with the most judicious 
management will require time, if it does not vanish as the local 
treatment advances. 

Nervous Excitability. 

Connected with it often in some manner is great nervousness, exci- 
tability, irritability, or exaltation of all the nervous phenomena. This 
nervous irritability shows itself in great mental excitability, want of 
sleep, unreasonable agitation, restlessness, dissatisfaction ; in short, in 
almost every phase of mental, muscular, or nervous excitement. 
There is also excitability of the different organs, with or without 
general nervousness, palpitation of the heart, nervous headache, local 

* See remarks on treatment of constipation. 



NERVOUS EXCITABILITY. 289 

muscular contraction, etc. Successful management of these nervous 
and excitable patients requires a careful scrutiny into their general 
condition ; the chylopoetic functions should be regulated in the most 
careful manner, the skin and kidneys should be attended to with 
great watchfulness. All that I have said as to general management 
in cases of nervous depression will a})ply to this kind of cases. As 
complete a revolution of the circumstances of the patient sliould be 
made as is practicable. From a life of ease, luxury, and absence of 
care, she should be, if possible, placed in circumstances requiring 
care, w^ith muscular outdoor exercise to the greatest extent she is 
capable of. If we cannot place our patients in situations which their 
cases require, we can send them on journeys that will demand exer- 
tion, calculation, care, and the deprivation of their usual domestic 
luxuries. The remark is frequently made that we must temper our 
remedies to the delicacy of the patients; and I am afraid that this 
injunction is misconstrued into the necessity of too great tendernes.s 
of treatment. The better rule is to make use of such means as will 
raise the patient from her state of delicacy to robustness. It is the 
delicacy of her constitution that causes her to suffer so much. This 
can be strengthened only by proper physical, moral, and mental 
training. The moral and mental condition of our patients when so 
very excitable should be attended to. Improper reading and society 
should be avoided, and social and literary habits should be reduced 
to great plainness and simplicity. Above all things, books and 
society should not interfere with regular rest, exercise, and outdoor 
exposure. As I have said before, this last should be as great in 
amount as can be borne, accompanied with active muscular exercise, 
as walking, and should be practiced in all weathers, sufficient pro- 
tection being secured by enough clothing of the right sort. With 
regard to the use of medicine, it is a fact, that it is an exceedingly 
difficult thino; to find anv remedv that does not produce exao^g^erated 
and in most cases disagreeable and even injurious effects. So much 
excitability of the nervous system nearly always modifies the effects 
of remedies, and we can seldom predict the operation of any of them, 
nor can we determine the value of any until they have been tried 
When tonics can be borne, they often very much relieve and sometimes 
entirely cure this great nervous excitability. Of the mineral tonics, 
probably bismuth, arsenic, and zinc agree best. Iron is not fre- 
quently tolerated in any shape by these very nervous patients. Qui- 
nine, nux vomica, cherry, and chamomile are the best vegetable 
tonics, but we must not be surprised if none of them are borne. Al- 

19 



290 GENERAL TREATMENT OF UTERINE DISEASE. 

coholic stimulants, In general, agree with them, and are the best cor- 
dials for temporary nervous excitement, but should be conscien- 
tiously avoided when possible, as not a few, T am sorry to say, of 
most estimable and intelligent women have used them too much, and 
engendered an appetite that could not be denied. Opium, and, in 
fact, the narcotics generally, fail to have any good effect, but on the 
contrary disagree with the patient totally. This, however, is not 
always the case with opium, as it acts like a charm with some. In 
all it should be studiously avoided as deleterious in the long run, and 
there is danger of creating an appetite for it. We may the more 
readily be persuaded to omit the use of all these medicines, as their 
effects are temporary, while hygienic and regiminal remedies are per- 
manent in their effects. The management of those cases of localized 
nervousness or unnatural excitability in particular organs, as palpi- 
tations of the heart, nervous headache, etc., is about the same as 
above, except that more attention to the stomach, from which they 
usually arise, may be necessary. 

Some forms of nervous excitement are very much benefited by the 
bromide of potassium. Severe nervous headache, watchfulness, and 
neuralgic pains are often greatly relieved by this remedy. It should 
be given in full doses. For headache, from thirty to sixty grains 
every hour until relief is obtained. For watchfulness, the same 
quantity an hour before and at bedtime will sometimes procure a good 
night's rest. When given in full doses it should be dissolved in a 
large quantity of water, to prevent it from irritating the mucous 
membrane of the alimentary canal. I have sometimes succeeded In 
averting the return of the syncopal convulsions described under the 
head of general symptoms. One patient now under my care had 
been the subject of them for twelve months, having them several 
times a month. They had become so frequent and violent as to 
induce the fear of epilepsy, and had been treated with many remedies 
without material benefit. She has been taking the bromide of potas- 
sium for six months In doses of thirty grains three times a day, and 
during that time has had no convulsions. She Is under treatment for 
endocervicltls. It remains to be seen, of course, whether this im- 
provement be permanent, nor can I say how mnch of the ameliora- 
tion may depend upon the treatment directed especially to the uterus. 
It Is certain, however, that the '^ paroxysms,'^ as she calls them, were 
improved immediately upon the commencement of the bromide treat- 
ment, and before I could reasonably expect benefit from the rest of 
the remedies. 



ANEMIA — LOCAL COXGESTION. 291 

AVe undoiibteclly have a valuable means of relief from the pains 
attendant upon the condition of many of these patients in the hydrate 
of chloral, while it is often as prompt and positive in the relief it 
affords in sleeplessness and pain. So far as I am aware, it is not fol- 
lowed by the very disagreeable effects that result from the adminis- 
tration of opium and its preparations. It, too, should be dissolved 
in an abundance of water, to prevent it from producing local irrita- 
tion upon the mucous membrane of the stomach, as it often other- 
wise causes vomiting or decided nausea. 

Ancemia. 

Anaemia, with its disagreeable concomitants, sometimes also calls 
for separate treatment. It would be an unnecessary waste of time and 
space to enter minutely into the general treatment necessary, where 
anreuiia is the prominent and troublesome symptom. This condition 
calls for the same treatment found useful under other circumstances, 
and, while it may not be entirely amenable to it, it will be very much 
benefited by the remedies indicated by the state of the blood. Iron, 
cod-liver oil, quinine, bitter infusions, and nutritious diet, with out- 
door exercise to the extent the patient can bear, are the ef&cient 
remedies. 

Plethora. 

B'.t we sometimes find general plethora instead of anaemia, a state 
in which there is actually an unusual amount and too rich a com- 
position of the blood. I need not dwell upon this general state of 
the system, as the treatment is simple and familiar. The great fear 
is that, on account of the painfulness about the hips and legs, the 
patient may be too much inclined to an inactive life. On no account 
should this class of patients be allowed their ease ; they must be urged 
to use up their surplus blood in active exercise, and the kind of exer- 
cise, next to the cares and labor of a household, best adapted to them, 
is walking. Every muscle in their body must be brought into action ; 
every secretion must be kept free, and the mind ought to be taxed to 
continuous effort during the day by some useful occupation, while the 
strictest temperance, with reference to ingesta, should be their rule of 
living. Obesity, and the troublesome and dangerous effects of plethora, 
connected or unconnected with general plethora, will be thus avoided. 

Local Congestions. 

AVe sometimes meet with instances of violent, dangerous, and even 
fatal determinations of blood to particular organs, as the consequence 



292 GENERAL TREATMENT OF UTERINE DISEASE. 

of the general ill-health which accompanies uterine disease, such as 
stupor, stertorous breathing, etc., indicating an oppressed condition of 
the brain, great dyspnoea, and sense of suifocation, showing congestion 
of the lungs. The treatment of these congestions does not differ from 
what would be appropriate under other circumstances of their occur- 
rence, and consists in revellents, alteratives, etc. The most frequent, 
and perhaps obstinate, of the local congestions are such as occur in the 
chylopoetic viscera, manifested by excessive secretion and discharges 
from the stomach and bowels. It is not uncommon for these patients 
to have suddenly recurring attacks of vomiting, cramps in the stomach 
and bowels, diarrhoea, and consequent great distress. Aside from the 
local treatment, we shall be called upon to exert our skill against the 
exhausting and depressing influences of these attacks. It will almost 
always be found that such attacks are preceded by constipation, with 
scanty secretions, furred tongue, and other evidence of unhealthy- 
secretions. By carefully correcting this condition we may avert these 
painful and exhausting occurrences. The plan recommended and so 
much prescribed by Abernethy will often palliate very much, viz., 
six or eight grains of blue mass, at night, worked off by some saline 
cathartic in the morning of every fourth or fifth day. If there is 
more permanent diarrhoea, great care should be exercised in the choice 
of diet; the use of warm baths should be recommended, very warm 
clothing, and not much medicine, as the cure will depend upon the 
appropriate treatment of the local disease, instead of the treatment of 
the general symptoms. All these symptoms, except the diarrhoea, 
are apt to be moderate, and can be borne until the diseased uterus is 
cured ; but there are two symptoms so very annoying, and which 
require so much patience in the treatment, and exercise so much 
unfavorable influence upon the uterine disease, that I hope I shall be 
pardoned by the reader for dwelling upon them more at length. 

Constijjation. 

I allude to constipation and indigestion, particularly the former. 
I have already spoken of the deleterious influence of constipation, 
and I think I am justified in saying that, if disregarded, it retards 
the cure of chronic diseases of the unimpregnated uterus more than 
any other sympathetic affection. And I wish to warn the practitioner 
to be very particular in attending to this symptom. There is proba- 
bly more tendency to costiveness in females than in males, chiefly 
owing to difference in habits. Sedentary life, confinement to close, 
badly ventilated rooms are among the circumstances that bring on 



CONSTIPATION. 293 

this condition. Irregularity of meals, late hours, deficient sleep, con- 
centrated diet, imperfect masticati<ni of food, all should be corrected, 
as any one of them alone will do harm, and all or any of these com- 
bined — and this is frequently the case — are very deleterious to the 
functions of the alimentary canal. But an inexcusable and very com- 
mon custom of most females is making the act of defecation a disa- 
greeable and procrastinated necessity, instead of a pleasant and punc- 
tual duty. The most trivial excuse — the presence of friends; a little 
cold, hot, or wet weather; being among strangers; or a slightly in- 
convenient distance from a proper place — will frequently be sufficient 
to limit defecation to once a week; then the act is performed in a 
hurried manner. It is amazinor to know to what lenoths this neo^li- 
gence is often carried. I have known two weeks to have transpired, 
frecpiently, according to the history of patients, without any attempt 
to relieve the bowel?. Xow this should be corrected by persistent 
method. The habit of eating from hunger at certain hours depends 
upon lifelong practice, and, when once established, cannot be changed 
without violence to many functions, causing urgent and repeated de- 
mands upon the system for a resumption of it. Regular bowels come 
from an equally long-continued habit of going to the close-stool at 
particular hours of the day. Years of negligence destroy the habitual 
regularity with which the bowels move; hence we should not be dis- 
couraged if the habit be not re-established without long perseverance. 
A new habit cannot be formed, nor an old one altered, without long 
and persevering effort in the right direction. AYe should, therefore, 
encourage a patient that is in earnest in her search after health, to 
persevere for months, years, and indeed her whole life if necessary, 
in going to her water-closet without fail, once every day, at a certain 
hour, as regularly as the clock points to it. This is indispensable to 
a correction of the bad habit of constipation. A very effective part 
of this regular endeavor is to cause the mind to dwell upon the neces- 
sity for an evacuation, and the process itself, for at least half an hour 
before retiring to the proper place. It is not a difficult matter, with 
many persons, to create a desire in this way. Let no consideration 
of convenience enter into this punctual effort at stool. Arrived at 
the pro}>er place, the position should be an easy one; no inconvenient 
strain upon any muscle should be allowed, and the patient should be 
possessed with an entire sense of leisure to perform the act completely. 
The value of all these considerations, where faithfully followed, is 
incalculable, and very few cases can long resist them. AVjthout them, 
medicine will only temporarily relieve, instead of permanently curing, 



294 GENERAL TREATMENT OF UTERINE DISEASE. 

obstinate cases. I should caution against severe effort, or straining, 
as it is called; let time, patience, and gentle effort be the plan. 
Another matter of great importance, when an effort is made to have 
an evacuation, is to have the abdomen distended by ingesta. The 
patient should be instructed to eat plentifully of vegetable diet, such 
as by its bulk is calculated to produce fulness. If the patient go to 
the water-closet with a sense of fulness in the abdomen, success will 
be much more likely. Should the regular time for making an effort 
be soon after breakfast, which is undoubtedly the best time, and the 
meal has not been sufficient to produce a sense of moderate distension, 
a full glass of water will complete that condition. For the purpose 
of giving fulness and a sense of distension, various kinds of ripe fruit 
may be resorted to with advantage. In prescribing fruit for consti- 
pation, we should bear in mind that there are three indications ful- 
filled by it, some kinds fulfilling all, while others fulfil only a part 
of them. They are, first and best, distension; secondly, increase of 
secretion, on account of the acids; and, thirdly, increasing peristaltic 
action of the bOwels by indigestible fibres, seeds, or rind. Ripe and 
mellow apples, without being divested of the rind, may be eaten in 
sufficient quantities to produce a sense of fulness, and this should 
always be at the conclusion of a meal, — breakfast, for instance; the 
acids will increase the intestinal secretion, and the rind quicken the 
peristaltic motion of the bowels by acting directly upon the mucous 
membrane, and through it on the muscular structure. Very acid 
fruits, as the lemon and orange, only produce their effect on account 
of the acids they contain. They are excellent as a part of the ingesta 
of patients whose stools are dry and hard and lumpy. Fruits con- 
taining an abundance of seeds, as figs, or of rind, as tamarind, etc., 
increase the peristaltic action without causing much secretion. By 
inquiring into the character of the stools, we shall have a good guide 
as to the kind or mixture of fruits to be selected. There are kinds 
of diet, breads particularly, that act like these last fruits, and may be 
used in conjunction with or independent of them. Breads in which 
the bran, or hull of the grain, is contained in considerable quantities 
are of this character. The Graham bread, as it is usually called, 
ordinary coarse, brown, corn bread, or wheat bread, are those mostly 
resorted to. When this kind of bread is used for constipation, it 
should be eaten at breakfast, dinner, and supper, in such quantities 
as the experience of the patient finds necessary. I have advised 
patients who could not use the coarse breads to make what may be 
called bran crackers. A tablespoonful of flour, oue pint of wheat 



CONSTIPATION. 295 

bran, two tablespoon fuls of white sugar, and water enough to make 
them all into a pasty mixture, are the ingredients. This mixture is 
made into cakes, small or large, as may be wished, and baked in an 
oven until hard. AVhen soaked in tea, coffee, or milk, they are not 
unpleasant. I have known patients benefited by swallowing certain 
seeds, with the rind, whole. A tablespoonful of wheat grains, oats, 
barley, white mustard seed, etc., can all be used for this purpose, and 
are not more disagreeable than medicines. Another kind of diet, 
which may be used to produce the kind of effect here aimed at, con- 
sists of the various small vegetables, as celery, radishes, pepper-grass, 
lettuce, asparagus, cabbage, etc. These may all be taken in quanti- 
ties to cause distension. 

In speaking of fruits, I ought to mention the berries as an excel- 
lent means, cheap, and easily procured, to accomplish all the objects 
attained by other fruits. 

Everything should be done by habitual effort, exercise, diet, drink, 
etc., before resorting to the use of medicines ; because, as is well 
known to the patients generally, as well as to the practitioner, the 
more medicines taken the more will be necessary. They lose their 
influence, and the dose must be increased in order to produce a full 
effect. This is almost always the case. Xot withstanding this evil, 
we are often reduced to the necessity of using laxatives to overcome 
constijDation. To a just and intelligent application of medicines in 
the treatment of constipation, it is indispensably necessary to make 
ourselves acquainted with the condition of the alimentary canal, with 
reference to its secretions and muscular powers. It will be found 
that there are sometimes great deficiency of secretion, and torpor or 
want of vitality of the muscular structure, or weakness of this tissue. 
The want of secretion may be in the upper portion, in which case 
the bilious color is wanting in the stools, or the small intestines may 
give out less watery material, and then the stools are less fluid, or 
even dry. The secretions may also be deficient in the lower portion, 
or colon ; in which case the fteces will be scybalous, dry, and lumpy. 
The muscular torpor, from want of irritability-, is more frequent in 
the colon or rectum than in the small intestines. When in the colon, 
there is increase in size of the lower abdomen, sense of fulness and 
hardness, and the faeces are expelled with great difficulty. If there 
is sufficient activity of the colon, but the rectum is torpid, large accu- 
mulations occur there, the pelvic distress is increased, and nervous- 
ness, general and local, is exceedingly annoying. Sometimes all 
these conditions are combined to render the case one of the most 



296 GENERAL TREATMENT OF UTERINE DISEASE. 

troublesome and difficult to manage. Mechanical obstruction by 
stricture of the rectum, formed by pressure of the uterus, may give 
rise to chronic constipation, which may become permanent and almost 
incurable ; or the uterus, by lying on the bowel, and pressing it 
against the sacrum, often gives rise to costiveness, that can be removed 
only bv correcting the position of that organ. It is not sufficient to 
know that the patient does not have regular operations from the 
bowels, but we must know wdiy she is thus constipated. Whether on 
account of want of secretion, and, if so, of what secretion ; whether 
it is attributable to general debility, combined with muscular weak- 
ness of the intestines, or to lack of irritability of the intestinal tube 
and consequent torpor ; and if so, whether this lack of irritability 
exists in the whole length of the canal, in the colon, or the rectum. 
AVe must also know whether there is obstruction from stricture in the 
rectum, piles, thickening in the mucous membrane, rigidity of the 
sphincter, or from the uterus bearing heavily upon it. To give a 
laxative merely because it ordinarily produces a fecal discharge, is 
always unphilosophical, and sometimes exceedingly injurious in its 
effects. I think it is inattention to the exact state of the alimentary 
canal that makes constipation so often incurable. For constipation, 
attended with very dry, hard stools, showing a deficiency in all the 
secretions from the bowels, in addition to the course of diet, includ- 
ing acid fruits, etc., our object should be to administer such drugs as 
will most effectually stimulate to secretion. The various saline med- 
icines are indicated. Sulphate of magnesia is a most excellent one ; 
and a good way of administering it is in combination with sulphuric 
acid. From one to two drachms, or even half an ounce, given in 
combination with acid enough to taste somewhat sharply, will pro- 
mote secretion along the whole of the small intestines, cause a large 
effusion of water, which will dissolve the fasces and render their 
evacuation easy and sure. In the morning, some time before eating, 
is the best time to take it. When there is reason to believe that the 
portal circulation is slow, and the liver furnishing less than its usual 
amount of secretion, some form of mercurial should be used with the 
salts. If the case is chronic and the constipation obstinate, we may give 
from six to ten grains of blue mass in pills, at bedtime, every fourth 
or fifth night, and follow it with Epsom salts in the morning. A 
continuance of this alterative cathartic from four to six weeks, seldom 
fails to cause a change in the alimentary secretions. Sometimes it is 
better to give these cathartics nearer, and sometimes farther apart. 
AVe must judge of this more by the susceptibility to the constitutional 



CONSTIPATION. 297 

influence of mercury than anytliing else. It is almost always the 
case that this very scanty state of the secretions is accompanied with 
an impoverished state of the blood ; hence iron in some shape will 
be beneficial in most cases. If there is much debility, a long course 
of tonics will be indispensable. It may often happen that this scanty 
condition of the secretions is attended with debility of the muscular 
fibre of the intestinal canal. When this is the case, we must add to 
the above treatment that which is applicable to this kind of intestinal 
torpor, which I shall now consider. Before doing so, however, I will 
remark that several other salts will answer as well, and sometimes 
even better, than sulphate of magnesia. The kinds of tonics which 
are most effectual in debility of the muscular structure of the in- 
testinal canal are such as give general strength, and it is most desir- 
able to combine them with special tonics. The latter are rhubarb 
and nux vomica. These have always seemed to me to have a special 
tonic influence upon the intestinal tube, and, when properly given, to 
increase the susceptibility to their own action. The rhubarb, although 
an alimentary tonic, induces less susceptibility to its own influence 
than the nux vomica. The best way to give the rhubarb is either in 
the root, without pulverization, or in the extract. When given alone 
in the root, the patient can take a little, twice a day, by chewing, 
and, after mixing with the saliva, swallowing it. A little experience 
will enable the patient to judge of the rio^ht quantity, which she can 
repeat as often as it is required. When the rhubarb is taken this 
way, she may also take a solution of ferri. sulph. and strychnia, in 
water, one grain of the former to one-sixteenth of a grain of the 
latter. 

I have often succeeded in overcoming this constipation or debility 
by giving one grain of quin. sulph. with five grains of powdered nux 
vomica after each meal. Or the same amount of nux vomica, with 
iron by hydrogen, two grains each time, after eating. It is usual to 
use aloes in the constipation of uterine diseases ; but I have found 
very few cases with which this drug did not disagree. But there is 
a torpor of the intestines where general tonics cannot be borne; 
Avhere, in fact, there does not seem to be any general debility, there 
is only a want of susceptibility to the stimuli which ordinarily arouse 
them to action. The secretions color the faeces properly, and give 
them sufficient moisture ; there seems to be no fault in their appear- 
ance, consistence, odor, or other character whatever. They are de- 
ficient only. The patient may be plethoric and florid, her general 
muscular strength sufficient, and her blood, so far as we can judge, 



298 GENERAL TREATMENT OF UTERINE DISEASE. 

good in composition. Special tonics and stimuli are indicated in 
such instances, and they alone should be used. Such measures should 
be adopted as will arouse the muscular action of the intestines. Nux 
vomica, in five-grain doses, with the rhubarb extract or without it, 
or the strychnia in solution, in doses from a sixteenth to a twentieth 
of a grain, constitute our most valuable medicinal appliances. This 
is the kind of constipation that is most benefited by and is most 
amenable to a persevering regiminal and dietetic course of manage- 
ment, such as I have endeavored to give. 

In addition to the rhubarb and nux vomica treatment, we may 
get some good from external appliances, and manipulations of the 
walls of the abdomen. The most valuable, when gently, persever- 
ingly, and methodically applied, is what is understood by the term 
kneading. The colon is the torpid portion in most cases of this sort 
of constipation. The process of kneading consists in handling it so 
as to stimulate its fibres directly. One plan is to grasp it with the 
hand, and squeeze it from one end to the other. We should begin 
at the right groin, and with a knowledge of the position and direc- 
tion of it, grasp it with both hands at this point, then a little higher 
up on the same side, and then a little higher, until we reach the right 
hypochondriac region. We should then follow it across the abdo- 
men to the left hypochondriac region, and thence down to the left 
iliac. Or, we may double our hands as bakers do when kneading 
their dough, and standing over the patient, press with the knuckles 
of both hands, first in the right iliac region, and imitating the pro- 
cess of kneading, pass slowly from this to the right hypochondriac, 
thence across the abdomen and down, as before directed. If we trust 
this process to a non-professional attendant, we should be sure to 
show him how to do it, as it is important that it should be done right. 
When this process of kneading or squeezing the colon is first insti- 
tuted, it should be practiced with the utmost gentleness, but the force 
and rapidity of motion may be increased until great freedom may be 
used. It should be resorted to a short time before retiring to the 
water-closet, say half an hour. Some patients find an efficient laxa- 
tive in what they sometimes call a water-compress, applied to the 
abdomen over night. It is made by doubling a napkin several times, 
so as to make a thick compress, large enough to cover the entire 
abdomen anteriorly. This is saturated with water, and, after beins: 
placed upon the abdomen, covered with a roller or bandage so as to 
keep it in place. It is thus allowed to remain from the time of 
going to bed until the time to rise in the morning. I think this 



CONSTIPATION. 



299 



Avater-compress is best adapted to cases iu which there is a deficiency 
of secretion in the intestinal tube. 

A bandage, or, what is better, a roller applied tightly enough to 
press the wall strongly upon the contents of the abdomen, frequently 
stimulates them to proper action, botli as it respects secretion and 
peristalic motion. When it is determined to use the roller or band- 
age for its stimulating influence, it ought to be applied upon rising 
in the morning, or, what is perhaps better, immediately after break- 
fast. This bandage should not be worn constantly, nor even many 
hours in the day. From the time of rising until two hours after 
breakfast, or from breakfast for three hours thereafter, will be long 
enough. The constant use of the bandage would but increase the 
evil — lax abdominal muscles — for which it is advised. Before leav- 
ing this part of the subject, I desire to say, with reference to the free 
use of nux vomica to overcome intestinal torpor, that in all cases we 
should remember its effects are cumulative, and quite a difference of 
susceptibility to its influence is manifested by different persons, in 
consequence of which the patient should be watched, and the dose 
graduated to the least quantity necessary in the case. Although I 
have given nux vomica and strychnia for a considerable length of 
time to a great variety of persons, and for several weeks together, I 
have never seen anything more than slight inconvenience from it in 
the shape of nervous startings. Very rarely we meet persons who 
cannot take it at all ; it disagrees with them as soon as they com- 
mence its use. 

There is another species of intestinal torpor of a very obstinate 
character and very distressing to the patient; I mean a lax, torpid 
rectum ; so torpid as to allow the fteces to accumulate in large quan- 
tities, and cause great inconvenience from pressure. To such an ex- 
tent does this collection sometimes go as to press the posterior walls 
of the vagina forward and protrude it between the labia. The first 
indication in such cases is to dissolve the fecal mass and discharge it. 
Various kinds of injections are useful for this purpose, warm oil, 
warm water, etc.; but one which I have seen do much good is com- 
posed of one ounce of fresh ox-gall and four ounces of warm water. 
This composition dissolves the fteces very readily, and the fresh bile 
stimulates the intestine to their expulsion. The evacuation, of course, 
will give only temporary relief, and there remains the most important 
indication, that of giving tone to the bowels, with a view of prevent- 
ing the accumulation in future. This is difficult, and in some in- 
stances of long standing quite impossible. Much good can be done 



300 GENERAL TREATMENT OF UTERINE DISEASE. 

in Dearly all cases, however, and we do not discharge onr duty if we 
do not try to relieve when we cannot cure every case. Cold water 
thrown into the rectum once or twice a day, in small quantities — 
eight ounces — is always good, without some special reason ' to the 
contrary. There are generally two indications to be fulfilled in these 
cases, — relaxation of the sphincters and r^toring the tonicity of the 
proper rectal fibres. 

It is a singular fact, which I thiuk I have observed, that the 
sphincter muscles increase in stre: ^: - :e of age; this 

is one of the causes why the fsoc^ uic vii^cd . ::,^ more di&culty 
in old persons. To give tone to the rectal muscles, astringent injec- 
tions have been recommended and extensively used : but in my prac- 
tice they have been almost uniformly useless, r::?::^ ^!r:. = injurious, 
and always disigreeable. They dry up tl -:::::-. an evil 
not to be compensated for by any other effect ; they do not, so far as 
I can judjre, cause contraction of the muscular fibres, but they are 
very apt, if persisted in for a length of time, to cause inflammation. 
I have derived more benefit from tonic suppositories and injection s 
than from any other kind of medicinal treatment. A suppository 
of twenty grains of extract of gentian, or five grains quin. sulph., ten 
grains of extract of comus Florida, or a mucilaginous suspension of 
any of these introduced into the rectum every night at bedtime, and 
retained, if possible, until morning, are good tonics and eligible 
modes of using them. It will be nece^ary, to secure the retention 
and efficient contact of these tonics, to first empty the bowels with 
ox-gall and warm water, and afterward introduce them with as little 
irritation as po^ible. The quantity of mucilaginous material should 
not exceed tw: : >, The tonic treatment of this kind must l>e 
varied, taking - : : r : : ': and then another, in first one form and 
then a dilferen: t : :st be kept up for a long time to do much 

good. We car: ^ ^reful, in all our treatment, to avoid any- 

thing to which iiie rectum shows any sensitiveness. When it be- 
comes tender and sensitive, we should at once desist until all of this 
has subsided before we are justified in beginning again. It too fre- 
quently happens that both the physician and patient become dis- 
couraged, and desist before the remedies have had a fair trial. Is 
there anything that will relax the sphincter ani ? I am not aware 
that any means operate with efficiency in this direction ; but I have 
used, in a few instances, with apparent Ijenefit, the ointment of bella- 
donna, made by mixing the extract with lard. I apply it to the 
anus externally upon going to bed at night, and continue it, until 



CONSTIPATIOy. 301 

the question against or in favor of its usefulness is fully deter- 
mined. 

This application certainly removes the irritability of the sphincter, 
which causes it sometimes to resist the extrusion of the faeces. 

As I have before remarked, there are cases in which this relaxation 
cannot be cured ; we are then compelled to resort to palliatives, and 
we must be careful to palliate intelligently. We are to give the weak 
rectum artificial support, to enable it to retain as near as may be its 
ordinary size. ThLs can be done only through the vagina. An air 
or sponge pessary introducetl into the vagina, so as to press the rectum 
against the sacrum, and thus diminish its capacity', will prevent the 
great accumulations from taking place, and in that way prevent one 
source of great inconvenience. Dr. Hodge recommends the globe 
pessary for this conditiou of the rectum, which answers very well in 
many cases, perhaps in the majority ; but each case must be studied, 
with reference to its own peculiarities, and the shape, size, and con- 
sistency of the pessary adapted to it. 

TThen our object is palliation alone, there is no objection to wear- 
ing the pessary all the time, but if it is used to palliate what we be- 
lieve to be a curable case, we ought to use it intermittingly, and the 
patient should not wear it at night especially. It would probably be 
better in a majority of the cases to introduce it l^efore rising in the 
morning, and allow it to remain until noon. One thing I think 
essential in the size and position of the pessary, and that is, that it 
does not compress the rectum l^elow its natural capacity ; there should 
be room enough for an ordinary amount of fieces in it, lest it become 
a source of obstruction, which it will do when larger or improperly 
placed. 

As will be noticed, I have omitted to say anything of enemata 
in constipation, from inactivity of the colon or up[)er portion of the 
alimentary canal. As an occasional means injections operate well ; but, 
like other laxatives, when used for a length of time they lose their influ- 
ence entirely. If we determine to use injections as an habitual laxative, 
by proper changes in kind and quantity, we may prolong their effi- 
cacy very much. To a person unused to them half a pint of cold 
water will act very well. When the bowels fail to respond to this 
quantity there ought to be an increase of two or three ounces, and 
then that amount used until its effects are not satisfactory, when a few 
ounces more should be added, and so on we may increase the amount 
until the quantity becomes intolerable. When this is the case we may 
order half a pint of water with a drachm or two of common salt, 



302 GENERAL TREATMENT OF UTERINE DISEASE. 

chlorate potassa, or nitrate of soda or potassa. We should increase 
the quantity of water or strength of solution, or both, as the suscep- 
tibility of the rectum is decreased, until we cannot carry either farther. 
After we have thus obtained as much good from injections as we can 
it is sometimes expedient to use suppositories as laxatives. Supposi- 
tories are made of laxative medicines, or of any other material. Com- 
pound extract of colocynth, or some other purgative extract may be 
used ; or we may inclose in some of the extracts a dose of podophyl- 
lum, or any of the purgative resinoids or alkaloids. These should 
be retained until absorption takes place. The common suppositories 
of soap, tallow, wax, sperm, stearin, etc., are of the second kind. It 
not unfrequently happens that the above modes of using injections 
and suppositories may be alternated very profitably, the full effects 
of each being experienced upon their resumption after having used 
the other for a time. But some persons cannot use injections; the 
rectum is too sensitive, and attempts to do so induce so much irrita- 
tion that they must abandon them. In such cases suppositories are 
out of the question. 

This form of rectocele sometimes requires a resort to surgery. The 
operation is detailed elsewhere. 

I have elsewhere shown that the uterus, by its wrong position, 
sometimes presses upon the rectum and obstructs the passage of the 
faeces. This may be effected by retroversion or prolapse. The indi- 
cation, of course, is to restore the uterus to its proper place, and as I 
shall have occasion to speak elsewhere of these difficulties (malposi- 
tions), I do not think it necessary to more than mention them here. 



CHAPTER XVIII. 



fPECIAL TEEATMEXT. 



Baths. 

The local treatment of infl:irQCQiitiou of the cervix uteri is made 
lip of several therapeutic items, varying according to the intensity, 
quality, and seat of disease. Of these there are, however, a few that 
are applicable to almost all cases ; hence their descriptiou, modes of 
use, etc., may l^e considered before going farther. Baths, injections, 
and some minor remedies are of this kind. Water, when applied to 
the surface, is purely sedative in its effects if it is of the temperature 
of the part on which it is used. If the bath is partial, the sedative 
influence is for the most part confined or limited to the part to which 
the application is made. So with injections per rectum or vagiuam. 
They soothe the parts contained in the pelvis. If the water is warmer 
than the part of the surface bathed, the effect is stimulant ; if it is 
colder, by virtue of the physiological action brought into play, it is first 
sedative and then stimulant. The circulation and nervous influence 
of the vagina, for instance, when the cold water is first thrown into 
it, are depressed, but very soon after its evacuation, or withdrawal, 
the vessels become excited to increased circulation of blood, and in- 
creased heat takes place and the nerves become more sensitive. In 
all these respects baths and injections act alike. The injections are 
internal baths, by which the uterus is bathed through the vagina. 
But the effects of baths and injections may be modified by containing 
medicinal substances. They may be rendered more stimulant or 
more sedative, or be even made to possess other qualities by impregna- 
tion with medicines ; one in very common use is astringent in char- 
acter. Another mode of using water and applying it, either simple 
or impregnated with medicine, is, to wet a cloth or a sponge with it 
and bind it to the surface, or introduce it into the vagina. Several 
thicknesses of cotton cloth applied to the abdomen and impregnated 
with water is what is called the water compress ; and often when 
allowed, to remain in contact with the skin for several hours it pro- 
duces considerable excitement, and, if persisted in for days, will 
cause first a vesicular, next a pustular, and finally a phlegmonous 
eruption. The way to render it effective is, after applying the wet 



304 5JI : 1 : z : z : 

cloth to cover it over with oil-silk, and then confine the whole with 
a bandage or roller, with a view to prevent evaporation. Sponge in- 
troduced into the va^^r ^ t^ : " "*rh water holding medicine 
in solution, is a common ^ . j : : :r : : i^ g me uterus. I do not d^ign 
giving an extended view of the e^cis of baths or their application and 
modus operandi, but so mudi aid is occasionally obtained by the use of 
them, that I cannot refrain fiom speaking of the application of some 
forms of them to disease of the uterus. The bath most applicable 
in inflammation of the cervix uteri and most commonly used is the 
sitz or hip-bath, which is intended to allay the inflammatoiy irrita- 
tion and pain. It is often the case that there is a great deal of suf- 
fering from pain without much inflammatory action in die parts ; in 
th^e cas^ a sitz-bath will often give great relief. In many instances 
the efficacy of the bath may be enhanced by having the patient in- 
troduce a speculum while in the water, so that it may pass up the 
vagina to the ne<i of the uterus and thus directly afl^ct the part dis- 
eased. In cas^ of medicated sitz-baths the oigan may thus receive 
the full benefit of the saline, anodyne, or other medicinal impregna- 
tion. The common gla^ tube will do veiy well for this use, where 
we wish only to bathe the neck of the uterus; but if we wish the 
fluid to come in contact with the vaginal walls and remain there for 
a considerable time, the wire speculum is the b^t. While speaking 
of the use of the speculum in this way, I may m^ition that a very 
efficacious mode of applying medicated washes without the bath to 
the cervix uteri or vaginal walls, is to have the patient lie upon her 
back, introduce the speculum^ and then pour the fluid info it. By 
remaining in that position she can retain the contact of the medicated 
solution as long as d^irable. Ice-water, ice, astringent powders, or 
almost any form of substance may be applied and retained in contact 
with the OS and cervix uteri with great advantage in this way. This 
mode of using remedies is particularly useftd in bleeding fungus or 
vascular tumor of any kind. 

The sitz-bath, when a patient is suf^ng with the pain and hear 
of uterine disease, may be used as often as neoe^aiy, twice a day ai 
least ; but three, four, or even a greater number of times will not be 
too often, when they are found to be soothing and useful. We may 
extemporize a hip or sitz-bath, by putting wata* in a common wash- 
ing-tub ; but the cheap tin vessels made for the purpose are within 
the command of alm<^ all persons. There should be so much water 



HIP BATH — SPONGE BATH. 305 

that when the patient sits down in it, the whole pelvis will be cov- 
ered. 

Temperature of the Bath. 

What should be the temperature of the bath ? The patient's sense 
of comfort, or discomfort, from its use, should be our guide in this 
respect. AVe should seek a temperature that is comfortable and 
soothing to the patient while in the water, and that leaves no sense 
of discomfort. The baths are intended for, and should add to, the 
comfort of the patient ; when they do not do this, they should at 
once be discontinued. As a general rule I advise my patient to take 
tepid water for her first baths, and then gradually use them cooler 
until they are cold, unless they become disagreeable in some respect ; 
if they do so, to continue them tepid. The colder a bath is, the 
more good it does, provided it be comfortable. The time for taking 
it may be regulated by the convenience of the patient, and the neces- 
sity for it, with the view of allaying pain, heat, etc. ; probably in the 
majority of instances, the most advisable times for taking it are upon 
rising and retiring. The length of time the patient remains in the 
bath should also be regulated somewhat by its effects. If the patient 
remains too long in the water it will debilitate her, particularly if 
there is considerable water and the bath is frequently repeated ; on 
the other hand, if she does not remain long enough, she will not de- 
rive any benefit from it. She may try remaining in it fifteen minutes, 
if she does not find herself very much relieved before that time, 
and she ought to be governed in her use of subsequent baths in this 
particular by the effects of the first few trials. While in the bath 
the intended temperature of the water may be kept up by adding hot 
water from time to time. The hip-bath is used almost wholly with 
reference to the local disease, but when general baths are required, 
it is usually for the relief of some attendant general symptom. 

Shower-bath. 

The shower-bath may be used as a roborant excitor of the circula- 
tion, if, upon trial, it can be borne, and produce a good effect. Some 
patients think they are very much benefited by the shower-bath, and 
say they cannot do without it. 

Sponge Bath. 

The sponge bath is useful in causing a tonic and soothing reaction 
upon the surface. Xeither of these can be tolerated by very feeble 

20 



306 SPECIAL TREATMENT. 

patients. The cold or tepid spoiio-e bath, administered at bedtime, 
not unfreqiieDtlv soothes nervous irritability, and enables restless 
persons to sleep soundly. I have not used baths in any other form 
than these, but when used as I have here indicated. I have seen such 
pleasant results from them that I cannot refrain from recommending 
them. 

Injections, 

Injections are applicable to almost all cases of inflammation of the 
cervix uteri, do a great deal of g^nd. and are believed to be sufficient 
to cure some cases. As I have b-fore said, they may be used as 
internal baths, to get the influence of water and temperature on the 
vagina and uterus, for the application of medicinal substances to th.e 
mucous surface of this cavity and vise -is. and also as detergents, to 
wash the vagina of all substances that should be removed from it for 
purposes of cleanliness. In some one of these forms injections may 
be used in nearly every sort of cervical inflammation. The simple 
injection of water may. and ought to be. used by all females who 
have inflammation of the uterine neck. The medicated injections 
can be useful only in cases where the inflammation is within reach 
of them, as when inflammation aflects the mucous membrane of the 
vagina, or the membrane covering the external surface of the vaginal 
portion of the cervix. For obvious reasons, injections containing 
medicines can hardly do any good, by virtue of the solution, when 
the inflammation is situated inside the cervical cavity. Vaginal in- 
jections cannot reach the seat of disease. I have not used intrauterine 
injections, as I think there are less hazardous modes of conveying 
medicines into the cavity of that organ. I should not discharge 
what I consider a duty, in this respect, if I did not condemn the use 
of the intrauterine injection. This method of reaching disease in the 
body of the uterus has lately been so strongly recommended Ijy a 
number of eminent men in the profession, that it will undoubtedly 
be more extensively resorted to than it ever has been before. I think 
this is unfortunate, and believe that sufficient facts have already l3een 
accumulated, showing the suffering and danger resulting from it, to 
condemn it, without subjecting this class of patients to the ordeal of 
a new trial. I believe a great amount of liarm has been done, and 
that much more will be perpetrated by it. My own observation was 
conducted under a conviction of the correctness of its philosophv, and 
with an earnest desire to avail mvself of everv o-ood means of curino" 
my patients. The result of such trials as I have made is, that thev 



MANNER OF USING INJECTIONS — KIND OF SYRINGE. 307 

have none of them been useful when used for any other purpose than 
checking haemorrhage in cases of abortion or uterine fungus. I think, 
also, that they are unnecessary, as safer and more efficacious methods 
have been devised for treatment of the mucous membrane of the 
corpus uteri. 



3Ianner of Using Injections — Kind of Syringe. 

The efficacy of injections depends very much upon the manner in 
which they are administered and the kind of instrument used. The 
essential quality of a syringe is its capability of receiving at one end 
and discharging at the other perpetu- 
ally, so that any quantity of water 
may be used without withdrawing 
and reintroducing the pipe. A large 
number of forms of syringe have been 
invented; but, for convenience, that 
form is, I think, preferable which 
has a vulcanized rubber, hollow ball 
mounted in the middle of a long 
flexible tube; by pressing on this 
ball, and relaxing it, the water is 
drawn in at one end and forced out 
at the other. A pewter, britannia, 
or ivory tube delivers the water into 
the vagina, and by its length may be 
made to convey it to the uppermost 
part of that cavity, and thus com- 
j)letely wash its walls. A siphon 
may be made to answer the same 
purpose, by having the fountain high enough to give some force to 
the current. Should the patient use a syringe of the above descrip- 
tion, she may sit over one vessel, and have the water in another in 
front of her. By inserting one end in the vagina, and the other in 
the vessel of water, the' whole of it may be made to pass through the 
vagina and fall into the vessel beneath her, and thus do away with 
the inconvenience of undressing:. 




Davidson's Syringe. 



IS 



An instrument 
Co., Boston, that 
syringing; they call it the fountain syringe. 



now made and on sale by Messrs. Burbank & 
in many instances is an admirable substitute for 



It is an india-rubber 
sac with a long tube depending from it. The sac is filled with 



308 



SPECIAL TREATMENT. 



Avater and hung up several feet higher than the patient; the tube is 
then inserted in the vagina, and, by means of the thumb and finger, 
the flow is regulated to suit the circumstances. I give a wood-cut of 
one that will convey a correct idea of them. 



Fig. 90. 




Fountain Syringe. 



Quantity of Injection. 

The quantity necessary to be used in an injection will vary very 
much in different sorts of cases. If water alone is to be used, and 
we wish to get the sedative influence, the quantity must generally be 
large, that is, from one to eight quarts; if we wish to stimulate the 
uterus with very warm water, a large quantity will also be necessary; 
if we wish the injections cold, it is better not to use so much. 

Medicated Injections. 

The medicated injections, also, should be large or small, according 
to the effect we wish to produce and the strength of the solution. A 
pint, or at most a quart, will be sufficient for astringent injections. 



ASTRINGENT INJECTIONS. 309 

We often use anodyne injections on account of their soothing influ- 
ence UJ30U the sensitive parts. As a general rule, anodyne injections 
need not to be very large, say a pint, or less, but the patient can con- 
tinue passing it through the vagina until its effect is attained. This 
may be done by using only one vessel, pumping from and allowing it 
to foil into the same. Frequency must be determined, also, by the 
object of the injection. Simple water injections can be used more 
frequently than medicated ones, and anodyne more frequently than 
astringent. The simple injections, if they afford relief, may be used 
from three to six times a day, or oftener; narcotics three or four 
times, or oftener. owing to the urgency of the symptoms requiring 
them and the good they are found to do. 

Astringent Injections. 

Astringent injections ought not to be made use of, as a general 
thing, oftener than twice a day, and in some cases to which they are 
applicable, this is entirely too often. Of all the vaginal injections 
used, the astringents are most commonly resorted to, and are produc- 
tive of most good. 

Jlodus OperojirJi. 

When an astringent is thrown into the vagina, the first elfect is to 
coagulate the mucus, pus. or blood, contained in it ; after this, its con- 
tact with the mucous membrane becomes more intimate, and its in- 
fluence is exerted upon the capillary bloodvessels, and the glandulae 
or crypts. The vessels are constricted in size, and circulate less 
blood, and the calibre and functional activity of the crypts are di- 
minished, and slight congestions and inflammations are for the most 
part cured, or at any rate benefited. When the vessels are circulat- 
ing too much blood, and the muciparous apparatus furnishing too 
much secretion, this astringency is desirable. We ought not, with 
certain exceptions, to use astringent injections when there is no hyper- 
_ secretion from the mucous membrane of the vagina or cervix uteri, 
nor an ulcerated or inflamed surface with which the solution can 
come in contact. 

Frequency of Using. 

The frec[uency with which they may be used must be indicated by 
observing these two effects, and the dryness more particularly. I 
think -we may lay down a rule for repeating them, like this : never 
repeat an astringent injection while the vagina is dry from the effects 
of a preceding one. We should, after obtaining the full astringency 



310 SPECIAL TREATMENT. 

of an injection, in the stoppage of a leucorrhoeal discharge, wait 
until the mucus afjain renders the mucous membrane moist. It will 
be found, very often, that this requires twenty-four and even thirty- 
six hours to take place. A disregard of this direction will some- 
times induce an increase of inflammation, and give our patient great 
inconvenience. In fact, too long a continuance of astringent injec- 
tions is apt to cause vaginal inflammation. 

Alternate Astringent Remedies. 

I think, however much an astringent may be indicated, that the 
same article ought not to be used more than twelve or fourteen con- 
secutive days, and should then be alternated with another one of the 
same class, or simpler ones. This last I generally prefer. A perma- 
nent dryness of the vagina after any one astringent, should preclude 
the use of that article at least, and cause us to try another, and so on 
until we get one that will agree with the case; or. else we must 
abandon all astringents, and fall back upon simple water. To get 
the full benefit of a medicated injection it should be preceded by one 
of simple water, in order to wash out the superabundant secretion in 
the vagina. 

Temperature of Injections. 

I know of no better rule to govern the temperature of injections 
than the comfort of the patient. After a trial of hot, tepid, warm, 
cool, and cold, let the patient suit herself by the effect they have 
upon her. Any temperature that is disagreeable should be avoided. 
The extract of opium makes a good anodyne injection. Five grains 
to a pint of tepid water, used for ten minutes, a quarter or half an 
hour, will often allay pain, arising from inflammation within the 
vagina, very readily ; or one grain of extract of belladonna may be 
used in the same way. In fact, we may choose among the narcotic 
extracts, remembering that the solution must be impregnated Avith at 
least three doses of the medicine. Among the astringents, alum is. 
the most common, the most useful and efficient. It possesses the ad- 
vantage of having no poisonous ingredient in it. As Dr. Bennett 
has taught us, it sometimes produces severe inflammation ; but this 
is, doubtless, owing to the inconsiderate use of it, and arises from its 
very efficacy in suppressing the vaginal secretion. One drachm to a 
quart of water, tepid, cold, or warm, as the patient may desire, is 
perhaps the strength of solution that will most commonly agree well ; 
but in this the patient should be governed by the sensation it leaves 



POSITION OF THE PATIENT — ACCIDENT IN INJECTION. 311 

behind. There should, at first, be a sense of dryness, quite obvious 
to the patient, which should pass entirely off in less than six hours; 
much better if it is entirely gone in two hours after the injection is 
administered. If this sense of dryness is perceptible, we should 
not allow the patient to use an injection for several houi^ after it is 
gone; and the longer it continues, the longer should be the interval. 
If it last six hours, the interval should be twenty-four; if two hours, 
the interval should be twelve ; if it last twelve hours, it should be 
discontinued, as it will most likely do harm. Another good astrin- 
gent is sugar of lead ; this is, perhaps, next in efficiency to the alum. 
Double the quantity may be dissolved in the same amount of water. 
I do not like sulphate of zinc, although highly recommended. Thirty 
grains of it may be dissolved in a pint of water, as an astringent in- 
jection. The sugar of lead, or zinc, ought not to be continued as 
long as the alum. Some of the vegetable astringents are often used 
to good advantage ; strong decoctions of oak bark, rhatany, kino, or 
a solution of pure tannic acid. This last is an admirable astringent, 
not less efficient than the metallic, but also less injurious. It can be 
used of the same strength as alum, or even double that strength, if 
desired. Injections and baths ought to be suspended during the time 
for menstruating ; if tepid and simple, they probably do no harm at 
this time ; but if cold or astringent, they are pretty sure to interrupt, 
more or less completely, this flow. Almost every practitioner that 
has had much experience in the treatment of uterine diseases has a 
favorite injection. I am disposed to adhere to the simpler forms, 
seeking rather for correct principles by which to be governed in ad- 
ministerino^ them, than for o-reat varietv of substances. 

Position of the Patient. 

The most favorable is the dorsal, recumbent, or knee-chest posture. 
In both these positions the vagina is thoroughly dilated so that the 
mucous membrane is well bathed by the water. The knee-chest is 
the preferable position when we desire to use concentrated solutions 
and have them retained in contact with the vaginal mucous membrane 
long enough to make a profound impression. 

Accident in Lijection. 

There is one annoying, and sometimes to the patient alarming, 
little accident that occasionally occurs during the reception of an in- 
jection in the vagina. Suddenly, while injecting the fluid, she is 



312 SPECIAL TREATMENT. 

seized with severe cramping pain in the hypogastric region, which 
radiates to the back and hii>s, down the thighs, and sometinies over 
the whole aMomen. She becomes sick at her stomach, is attacked 
with rigors, and her feet and hands often become cold. This pain 
continues, witli exacerliations and remi^ions, for several minni^ or 
hours, and when it subside, leaves a sense of soreness, more or 1^ 
considerable, corresponding with the severity of the attack. As the 
chilliness and rigors of the first few moments subside, there is reac- 
tion ; the patient becomes warm, and sometime decidedly feverish. 
In all cas^ in which I have witne^ed th^e symptoms the patients 
were using a syringe, in the end of which, within the vagina, were 
several perforations, some on the side of the bulb at the end, and one 
at the very extremity. I think that one of the perforations had been 
accidentally placed in apposition with the external os utferi, and as the 
water was forced through this perforation, it entered the cavity of the 
cervix, and passed through into the cavity of the body of the uterus, 
inducing the first shock, and the pains following it were caused by 
the spasmodic attempts on the part of the nterns to expel it. Al- 
though I have, in a large number of instance, been called upon to 
^vitness and prescribe for these symptoms, I have not seen them pro- 
ceed to dangerous extremities. I think these are cases of injection 
into the womb ; and, in this resi^ect, they constitute my whole ob- 
servation. An opiate injection per rectum, fomentations over the 
pubis, and quiet, are all the remedies I have found necessary. And 
often the symptoms sulfide so soon that I have not been under the 
necessity of prescribing at all. 

We occasionally meet with patients who cannot use baths or injec- 
tions. In these cases it will be found, almost invariably, that this 
inability arises from their producing an exa^erated effect. If it 
is simple tepid water used for the bath or injection, its r^ults are too 
sedative. The bath debilitates the patient, instead of simply sooth- 
ing her. I have seen a single tepid bath prostrate a patient so that 
she would have to lie in l^ed for several hours before its effecte wore 
off. A cold bath induces chilliness and permanent eoldn^s, and re- 
action is not established ; the system recovers from its effects only 
after a number of hours, and that slowly. Hip, sitz, or general 
baths may produce these effects, and when they do so, should be 
almndoned as injurious. Other nervous symptoms, as difficultv of 
breathing, nausea, dysuria, etc., also occasionally seem to be the 
effects of baths. It is singular that some patients are so susceptible 
to the depressing effects of water that injections debilitate them very 



BATHS AND INJECTIONS IN PREGNANCY. 313 

rapidlv, and they are obliged to abandon them on this account. Cold 
water, as an injection, not unfrequently causes general coldness. But 
it is the medicated injections that most frequently produce an exag- 
gerated effect. Alum injections, even when the solution is weak, w^ith 
some patients, produce such disagreeable and constant dryness, and 
sense of heat, as to make them quite intolerable. And the sensitive- 
ness of the vagina becomes so great that some patients are forced to 
cease the injections of alum wholly. The same objections apply to 
other astringents to a less degree, and the consequence is, that how- 
ever baths and injections may seem to be indicated, in the cases where 
idiosyncrasy renders them so objectionable, we must forego their use 
entirely. 

Should they be used in Pregnancy f 

Is pregnancy an objection to the use of local baths and injections ? 
I think not with proper care. A hot bath about the hips would be 
objectionable; a very cold bath that might cause much of a shock, or 
internal congestions, would not be advisable ; but plenty of tepid 
water, and even cool water, temperately used as baths, give the preg- 
nant woman great comfort, and cannot generally be followed by any 
bad effect. Injections may be used with less caution than baths. 
The caution which we would administer to all is, that they should 
not be copious. In pregnancy the patient ought not to use more than 
a quart at one time. The injections should always be tepid or cool ; 
not very cold nor very warm, lest they stimulate the muscular, vas- 
cular, or nervous system of the uterus too much, and induce haemor- 
rhage, or provoke contractions. Both of these effects, I think, I ha^^e 
known produced by such injections; the cold causing contraction and 
expulsion ; and the very warm haemorrhage and death of the ovum. 
Strong astringents should also be avoided. Much comfort may be 
derived from anodyne injections, when there is neuralgic suffering 
about the uterus or vagina, during pregnancy. Cases of superficial 
inflammation, and even early ulceration of the vaginal portion of the 
cervix, may alwavs be benefited by injections, baths, and the general 
treatment which I have heretofore detailed. In fact, most cases, if 
not all, w^here there is no idiosyncratic objection to the baths and 
injections, will be very much benefited by them. When, however, 
the disease has been of long standing, or extends between the labia 
of the OS uteri, or into the cavity of the cervix, these will only slightly 
benefit it. AVe must then seek for something that will more pro- 
foundly influence the nutritional changes, and the vascular and 
nervous tissues of the parts. 



314 SPECIAL TREATMENT. 

The introduction of anodyne, astringent, and alterative ointments, 
pessaries, and powders, may be resorted to with much profit in many 
instances. The small instrument called the suppository syringe will 
enable the patient to place ointment in contact with the uterus very 
conveniently. Ointments made with opium, belladonna, hyoscy- 
amus, cicuta, tannic acid, mercury, iodine ; in fact, almost any sub- 
stance used to exert an influence locally, may be made into ointment 
and thus introduced. The powders of many of these articles may be 
deposited in the vagina in the same way. And the medicated pes- 
saries made by mixing the medicine intended to be used with cacao- 
butter, may be passed up to the os uteri through a glass speculum, 
either by the patient, her attendants, or the physician. In using the 
narcotics in the vagina, in the form of ointment or pessary, we can 
safely use double the quantity given by the stomach. The ointment 
is absorbed slowly, and consequently it requires some time to effect 
much by it. But the powders act much more readily. Morphia thus 
introduced will sometimes act with great promptitude, and the powder 

Fig. 91. 



of tannic acid is a very efficient astringent used in this way. The 
absorbing power of the vaginal mucous membrane is decidedly less 
than that of the rectum. It takes a longer time and more of the 
medicine to affect the system through this cavity. Possibly this may 
be to some extent on account of the more ready escape of substances 
from the vagina; but I think, also, the membrane does not take up 
substances so quickly. From this fact injections or suppositories per 
rectum will often do more good in allaying pain especially than 
when used per vaginam. A few drops of strong solution of sul. 
morphia in the rectum act very promptly. Dr. Greenhalgh and 
others use cotton pessaries medicated per vaginam. The cotton is 
prepared by immersing it in a strong solution of the medicinal agent 
to be employed, and afterward drying before using it. Still another 
method of making local applications to the upper part of the vagina 
is to envelop the medicines in a sac of thin cotton or linen goods, 
and pass it up to the cervix, and let it remain there until the astrin- 
gent, or whatever may be contained in it, is dissolved out, and exerts 
its influence upon the parts. The patient can use this kind of appli- 
cation without assistance. 



LOC^L TREATMENT. 315 



LOCAL TEEATMENT. 



There are very few cases of chronic inflammation and congestion of 
the uterus that may not be benefited by what is known as local treat- 
ment. This is especially true with reference to those cases in which 
the intensity of the disease is sufficient to cause the loss of the epithe- 
lium or deeper portions of the mucous membrane, — abrasion or ulcer- 
ation. Local treatment is not only beneficial but indispensable to 
the cure of endometritis and endocervicitis. 

Local treatment consists in the application of certain medic'nes 
directly to different parts of the uterus and vagina for the relief of 
the various conditions connected with the inflammation. The medi- 
cines and the methods of their application are intended : first, to 
relieve pain by their anodyne influence; second, to deplete the parts 
of the superabundance of blood; and, third, to change the character 
of the capillary circulation by restoring its natural activity. 

When there is much pain of whatever character the anodyne ap- 
plications are indicated ; and many patients will bear anodynes as 
local applications for the relief of pain very much better than when 
taken internally. Even where there is no idiosyncrasy forbidding the 
use of anodynes, they may dflPect the stomach on account of their taste, 
so that they cannot be borne or will not be taken. 

Suppositories made by impregnating cacao-butter with a quantity 
of the anodyne to be made, fifty per cent, larger than when taken in 
the stomach, and repeated as frequently as required, is one method 
of making anodyne applications. The suppositories are made by the 
apothecary in a shape and of a size for the vagina, and also for the 
rectum. It requires a longer time for the anodyne to be absorbed by 
the vaginal membrane than by the stomach or rectum. 

When it is desired to use the suppositories in the rectum instead 
of the vagina it will require no more than the ordinary dose of the 
medicine, and the efi'ect is obtained more promptly. It must be re- 
membered also that the mucous membrane of the rectum is very 
much more sensitive than that of the vagina. When therefore we 
desire to use medicines, the primary effect of which is irritation, as 
chloral or bromides, it will be necessary to dilute them more than 
for the vagina. Topical applications of anodynes may be made in 
various other ways, by inclosing the medicines in a sac of thin cotton 
cloth, gauze, or domestic, and placing it in the upper part of the 
vagina, or entangling it in cotton-wool and putting it near the cervix. 

Sometimes the medicine may be applied in solution, the patient 



316 LOCAL TREATMENT. 

lying on her back so that the fluid may gravitate to the cervix. 
Half an ounce of fluid introduced through an ordinary glass or 
rubber syringe will generally be retained — if the patient continues 
the dorsal position — until it affects the nerves of the part. Appli- 
cations of this kind can be made by the patient herself, or the nurse. 

Topical depletion in inflammation and congestion of the uterus is 
also a most valuable curative measure. When the uterus is very 
tender and sensitive to the touch, it will require but little irritation 
to cause intense local inflammation. We must be especially careful 
under such circumstances to avoid the third class of topical appli- 
cations. 

The tenderness and sensitiveness depend upon an unusual intensity 
of inflammation in the fibrous structure of the uterus above, which, 
although chronic in duration, is subacute in grade. This kind of 
turgidity, sensitiveness, and pain is sometimes kept up by the pres- 
ence of perimetric inflammation — cellulitis — local peritonitis, cystitis, 
etc., and they contraindicate any stimulating applications to the 
uterus. It is in the conditions just described that local depletion is 
applicable and beneficial. Common means of local depletion are 
leeches and scarification. Leeches may be applied directly to the 
uterus through the speculum, around the anus, over the sacrum, or 
pubic region. When we desire to apply them to the cervix, some 
preparation will be necessary to insure success. The vagina must be 
thoroughly washed by large injections of hot water to remove any 
offensive secretion or other contents of the vagina. The cervix may 
then be exposed by the speculum and sponged with sugar and milk, 
and it will add to the readiness with which the leeches take hold to 
prick the cervix until it bleeds, and then smear the surface with the 
blood. The leeches are first thrown into tepid water, and from it are 
taken out, placed in contact with the cervix, and watched until they 
fasten upon it. The number employed — from four to twelve — will 
be governed by the amount of turgescence and pain ; when the in- 
tensity of inflammation is very considerable the greater number. In 
judging of the number necessary, we must be governed by the pain, 
tenderness, and general condition of the patient. The pain and 
tenderness must be such as are caused by local hypersemia — inflam- 
matory or congestive — or by inflammation in the surrounding tissue, 
and not the pain and sensitiveness of neurotic conditions of the parts 
or the patient. I do not mean neuralgic pain as that term is generally 
understood, but hyperaesthesia unattended by any hypersemia. 

Scarification cannot be made to take the place of leeches, but it is 



LOCAL TREATMENT. 317 

often followed by great improvement, and is very efficient in remov- 
ing congestion of the submucous tissues. It may be performed by 
any long pointed knife by which the cervix can be reached, but per- 
haps the more efficient instrument is Buttle's artificial leech. 

Fig. 92. 



Dr. Buttle's Uterine Scarificator and Leech, very efficient and convenient for abstracting 
blood from the engorged Cervix Uteri. 

It is a very small spear-shaped knife mounted upon a long shank 
and handle. With these instruments, the most dependent parts of 
the cervix may be pricked in sev^eral places. The bleeding may be 
encouraged by injections of tepid water in large quantities. 

Fig. 93. 



Knife for Scarifying the Cervix. 

In what time of the mouth is depletion the most useful ? Before 
the commencement of the flow as a rule there is the greater amount 
of hypersemia. and conseqyently is the time we might effect the most 
good from depletion. This is not always the case, however. There 
is no question that patients who have febrile excitement during 
the time of the antemenstrual congestion are very much benefited 
by local depletion at that time, but much more frequently the cases of 
lingering congestion will require it oftener. 

When the menstrual flow is deficient and the uterus is not re- 
lieved by it many women are relieved by leeching or scarifying the 
cervix. 

The congestion which lingers after the menstrual period and causes 
so much suffering, is generally, although not always, the result of a 
very scanty flow. In either case, when we determine to deplete, it 
should be done as early as the close of the flow, at latest, and if the 
flow is scanty during the discharge. 

Independent of these physiological reasons for selecting these times 
for depletion, and notwithstanding the fact that thus used the deple- 
tion is generally attended with the best results, the very best rule for 
our guide will be found in the symptoms. In most cases there is a 
particular time in the month when the symptoms are the greatest in 
intensity ; that is the time to deplete. In some this intensity occurs 
before, in others during or immediately after, the flow, while in still 



318 LOCAL TREATMENT. 

another class of patients it is midway between the periods. Rarely 
there are chronic cases where the congestive or inflammatory symp- 
toms last all the time. When there is enough general vigor, these 
will be improved by depletion two or three times a month. 

In connection witli the measures for depletion, glycerin deserves 
to be mentioned. When placed in contact with the surface of the 
body, its strong affinity for water attracts the serum of the blood from 
the capillary bloodvessels very rapidly. This process is very much 
more active in the vaginal cavity, where the air is to a great extent 
excluded, as the whole capacity of the glycerin to take up moisture 
is exerted upon the membrane by which it is surrounded, and a large 
quantity of serum is rapidly abstracted from the diseased parts. The 
tumefaction and tension are at once removed and the pain relieved. 

When a glycerin tampon is placed in the upper part of the vagina, 
it requires but a few minutes to establish a copious watery discharge, 
that lasts until the glycerin, diluted w^ith several times its own weight 
of serum, is washed out and exhausted. 

The relief which follows this application of glycerin is often even 
more marked than after depletion by leeches. Glycerin was first 
used as a dressing in vaginal operations by Dr. Sims, and it required 
but a little time for him to discover its valuable properties as a means 
of relieving inflammation and congestion. Used in this way I con- 
sider glycerin invaluable. As a lubricant or solvent for local appli- 
cations I believe it to be worse than useless. To dissolve medicine 
in it, and then apply it to the cervix, is to insure the rapid removal 
of the medicine by a current of serum poured out from the surface. 
For this reason absorption from a glycerin solution, applied to the 
vaginal surface, is simply impossible. The efficacy of glycerin appli- 
cations depend very much upon their preparation and the method of 
using them. 

The best quality of cotton batting is the substance most appropriate 
with which to make glycerin applications. There is a great differ- 
ence in the grades of cotton batting in the market, and w^e should be 
careful to get the best article made. It absorbs a larger quantity of 
glycerin, and does not wad up into such a compact mass as an infe- 
rior article does. In preparing the glycerin cotton for use, it should 
be made into a round ball, about an inch and a quarter in diameter, 
when loosely pressed in the hand. This may be secured by passing 
a strong thread around it, having the thread long enough to bring 
out of the vagina, so that the patient may be able to remove it; or 
the cotton may be rolled into the shape of a cylinder, two inches long 



LOCAL ALTERATIVES. 319 

and one in diameter, and secured by a thread. Every piece to be 
used should be thoroughly saturated with the glycerin. It is not 
sufficient to impregnate the surfiice of the cotton ball with the medi- 
cine, but every fibre should be saturated with it. This requires some 
time to accomplish, and it will be well for office use to submerge the 
cotton in a jar of glycerin and let it lie until it becomes saturated. 
^Mien we use these, if they are thus saturated, they may be gently 
pressed until the glycerin will not flow from their surface. 

The speculum will be necessary to a perfect application of glycerin, 
and the cotton must be placed in contact with the diseased surface. 
One or more of these pieces may be applied according to the capacity 
of the vagina or the amount of congestion. Glycerin thus used may 
be applied every third day, and if the cotton is well saturated, allowed 
to remain twenty-four hours, when it should be remov^ed. 

Cotton treated with glycerin in this way is not fit for a support to 
a displaced uterus, and too frequent use of these applications is occa- 
sionally followed by a sensitiveness of the mucous membrane that 
renders them intolerable. 

It is not often that we rely upon glycerin applications for a cure, 
or even as the principal remedy. It is more commonly used as an 
adjuvant or a palliative measure to follow stronger applications. 
When we are under the necessity of making a strong application to 
the cervix and vagina, to follow it immediately by glycerin prevents 
the severe consequences that sometimes follow. 

Local Alteratives. 

The many remedies applied to the inflamed and abraded surfaces 
of the cervix, while they fulfil the general indication of changing the 
action of the nerves and vessels of the parts to which they are applied, 
their special eflects are not precisely the same. There is certainly a 
wide difference between the local effects of tannin and nitric acid, of 
tincture of iron and nitrate of silver. Yet we find them all, and 
many others, used in the same kind of cases, one or two of them re- 
garded as quite sufficient to cure a large majority of cases. This is 
the case with iodine, carbolic acid, and nitrate of silver. The prac- 
tice of experienced gynaecologists, in the use of these local remedies, 
is remarkable in the fact that a very few can agree upon the same 
articles. To the inexperienced this is perplexing; but it is account- 
able for by the consideration that anything which will excite the 
vasomotor nerves sufficiently to increase the sluggish capillary circu- 



320 LOCAL TREATMENT. 

latloD, — an essential item in the process of congestion and inflamma- 
tion, — will induce a change in the morbid tissue to which it is applied. 
Astringents, stimulants, caustics, etc., have this effect, and so will the 
mechanical influence of friction or pressure. This consideration does 
not justify indifference as to the choice of local applications, for there 
are other differences than degrees of intensity in their action. There 
is, therefore, room and reason for selections, which will give quite a 
range in our choice. We should continually bear in mind that all 
irritants applied to the cervix as local applications, produce their 
effect upon the vasomotor nervous system primarily, and, secondarily, 
upon the circulatory and absorbent functions of the vascular system, 
and that in consequence of the unity of the vasomotor nervous appa- 
ratus of the cervix and body of the uterus, any impression made upon 
the neck is reflected upon the body, and conversely. The reflected 
influence is felt not only upon the vessels, but also upon the fibrous 
structure of the uterus. This explains the effects of therapeutical 
measures applied to the cervix. 

There are also certain remedies which, when applied to the cervix, 
exert an influence through the blood. Mercury and iodine are un- 
questionably absorbed, and they may have a double influence upon 
the local disease, first, by the direct stimulating eff'ect upon the nerves 
of the part, and, secondly, by their well-known general alterative in- 
fluence. I have several times seen a marked ptyalism follow a single 
moderate local application of the solution of pernitrate of mercury, 
and it is not an uncommon thing for patients to complain of a me- 
tallic taste in the mouth in a very short time after an application of 
iodine or mercury. AVhen thus they obviously enter the circulation, 
they may be expected to exert the same influence upon the eff*usion 
in the substance of the cervix and body of the uterus as if taken 
internally. 

Locally iodine, in the form of the ordinary tincture, ChurchilPs 
tincture, and other alcoholic solutions, is a very strong stimulant, and 
is scarcely caustic in any of these solutions. It is, therefore, in these 
forms, an excellent application when we desire to produce a strong 
but superficial effect upon the mucous membrane of the vagina, cervix, 
or cervical cavity, and should not be repeated often. A solution made 
by dissolving one part each of iodine and iodide of potassium in one 
part of alcohol makes a very efficacious application, made by a swab 
once in a week or ten days to the erosions of the cervix, connected 
or not connected with laceration. Their local effects applied in this 
way excite the capillary circulation of the whole uterus to recuperative 



LOCAL ALTERATIVES. 321 

activity, and thus cure up the erosions and cause the absorption of 
the deposit in the areolar tissue. Iodine is again used in a different 
way and for another purpose ; that is, in a non-irritating form, in 
which it may be absorbed and expend its influence as an aherative 
through the circulation. It is often dissolved in glycerin and ap- 
plied on cotton to the cervix. The solution of iodine in glycerin for 
an application is almost, if not entirely, useless, so far as the iodine 
is concerned, for it is very soon washed out of the vagina by the 
serum drawn from the parts by the glycerin. 

The very best way to obtain the fullest alterative effects of iodine 
as a vaginal application is to impregnate cotton-wool with iodine by 
mixing the crystals of iodine with the cotton, and then placing them 
in a well-stoppered bottle in a moderately warm place, when the 
iodine will become volatilized and diffuse itself thoroughly, fully, 
and uniformly in the cotton. This cotton may be applied through 
the speculum to the cervix, and allowed to remain there for twenty- 
four hours. This application may be used every fourth or fifth day. 
It is a very common practice to combine iodine and other medicines 
for local applications. Iodine and carbolic acid, called iodized 
phenol, is combined in the proportion of one part of iodine to four 
parts of carbolic acid. 

This mixture is a favorite one with Dr. Eobert Battey, of Rome, 
Georgia. He has written an able paper, "^ detailing its effects in endo- 
metritis. His indoi^ement, as a local application in this form of dis- 
ease, is a sufiScient guarantee of its usefulness. 

The solution of pernitrate of mercury (acid nitrate of mercury), 
because of its valuable alterative influence, deserves particular notice. 
Unlike iodine it is strongly caustic, aud can be made to destroy the 
parts to a great depth. In this respect, perhaps, it is about equal to 
nitric acid. The application of these remedies, however, can be made 
without destroying the tissues ; and now that we know the salutary 
influence of our applications does not depend upon " burning off the 
ulcer,^' or cauterizing the abrasion, but that their efficacy depends 
upon the excitation they produce upon the submucous vessels, these 
medicines are used very differently. 

The acid nitrate of mercury should be applied by the cotton 
swab so lightly as not to cauterize. The cotton should be dipped into 
the mercury solution and saturated with it, and, before being applied, 
pressed firmly between two wooden surfaces until it is merely moist 

* Eead at the meeting of the British Medical Association for 1S79, held at Cork, 
Ireland. 

21 



322 LOCAL TREATMENT. 

witli the solution. The cotton thus prepared is a2)plied to the sur- 
face ; it coagulates the mucus on the surface merely. The application 
in a few hours is followed by local reaction in the capillaries imme- 
diately beneath the part, which, in a certain degree, is salutary. It 
is not best to use this for congestion or inflammation, attended or not 
with abrasion, oftener than once in two weeks or a month. The 
second day after the menses is the best time. Carbolic acid, in solu- 
tions of various strength, is a popular medicine for local application 
to the cervix uteri. The 95 per cent, solution is equal in stimulating 
influences to that of the nitrate of silver of 20 per cent, strength. If 
used exclusively, or as the main article, for stimulating the inflamed 
cervix, it may be applied once a week. 

Among the astringents the preparations of iron solution of the per- 
sulphate and the tincture of iron are frequently used. The tincture 
of iron, once in five or six days, is very generally used wath great 
benefit. 

The nitrate of silver, once so popular as a topical application, has 
fallen into disrepute, and is seldom resorted to by our best gynaecol- 
ogists. The main objections to it are the great pain it often produces, 
the intensity of the submucous capillary excitement it causes, which 
sometimes extends to the cellular tissue; the amount of haemorrhage 
it often causes, and its severe effects upon the nervous system. But 
the most important objections to it, perhaps, is the shrinkage and 
condensation it brings about in the cervix. 

After it has been used with anv thoroughness for a long: time the 
cervix, and sometimes the uterus, is diminished in size and indurated. 
Although haemorrhage is a common symptom immediately following 
the application, it is not unusual that the protracted use of it leads to 
suppression, more or less completely, of the menstrual flow. It must 
be admitted, however, that these objections apply more to what, in our 
present knowledge of its effects, we would consider the injudicious 
application of it in solid form. In solution it may be made to produce 
an alterative influence that is difficult to effect with any other remedy. 

A 50 per cent, solution, applied with the swab, is not a caustic, 
and is not amenable to the objections just above mentioned, and 
intended to apply to the solid form. 

Whatever the application may be, it should not be repeated if fol- 
lowed by evidences of serious irritation, as pain, lasting for over an 
hour ; tenderness in the iliac or hypogastric region ; chilliness or 
febrile excitement. 

When an application is made from which we expect any consider- 



TREATMENT OF ENDOMETRITIS. 



323 



able pain or reaction the patient should lie down and remain quiet 
until all sense of inconvenience has passed away. 

As before remarked, we may frequently secure immunity from 
suffering by following the application with a tampon of glycerin 
cotton. 

Treatment of Endometritis. 

When the disease is confined to the cervical cavity the simpler 
forms can be cured by the same kind of application made use of in 
the treatment of ordinary inflammation and abrasion of the cervix. 
To make these efficacious it will be necessary to remove the mucus 
from the cervical cavity by wiping it away with cotton, wdien that is 

Fig. 94. 




Small hard-rubber Syringe, to wash out the Vagina, or cleanse the Neck of the Uterus. 

practicable, and, when not, it may be removed by such a syringe as 
is represented in Fig. 94. 

With the ordinary flexible applicator, wrapped with cotton, the 
remedy is passed into the cervical cavity up to the internal os uteri. 
The same precaution should be observed in other cases in which the 
application is made. 

The treatment of these simple cases is really not more difficult than 
when the disease is on the outer cervical mucous membrane. And 
as the external cervical inflammation, with erosions, coexists with 
the endocervical, they should both be treated at the same time, 
by first making the application externally, and then passing it into 
the cervical cavity. 

We sometimes meet with an obstinate yet uncomplicated form of 
endocervicitis, or cervical catarrh, that resists all of the usual remedies. 

The cervix is filled with an extremely tenacious mucus that is re- 
moved with great difficulty, the cavity of the cervix is enlarged, and 
when the mucous membrane is exposed may be seen to be very rough, 
granulated, and scarlet red. The granular eminences are the en- 
larged muciparous glands, the glands of Naboth. Dr. Sims* reports 

* Transactions of the American Gynaecological Society, 1879. 



324 LOCAL TREATMENT. 

cases of this kind cored by thoroughly scraping the cervical cavity 
with a sharp curette, and afterwards touching the surface lightly with 
the actual cautery. Dr. Isaac E. Taylor, of Xew York, says he has 
resorted to this treatment with great success. 

AYhen the inflammation extends to the cavity of the body of the 
uterus the treatment is more difficult of accomplishment, attended 
with less satisfactory' results, and sometimes followed by severe symp- 
toms. 

When it is uncomplicated, and the cervical canal at both extremi- 
ties are patent, the treatment is generally simple and efficacious. The 
applications adapted to this form of disease are the same as for endo- 
cervicitis and are made in the same way. The applicator charged 
with the remedy is carried to the fundus, and by a gentle rotary 
movement made to touch the whole endometrium. 

Ordinarily these applications are not very painful. This form of 
endometritis, when the cervical canal is sufficiently open, may also be 
successfully treated by the dull-wire curette. This instrument may 
generally be passed with great ease, and, after it is introduced, it is 
gently passed over the whole surface of the cavity. This can be re- 
peated once a week if necessary. 

I could report several cases where the curette used in this way has 
done more good than any other remedy I had used, and apparently 
completed the cure. 

The curette in these cases is used, not for the purpose of cutting 
away any portion of the living membrane, nor for removing growths 
or granulations, but for the pur^^ose of stimulating the circulation in 
the mucous membrane. 

When endometritis is complicated, the treatment will of course be 
very much modified by the complicating circumstances. Stenosis 
from contraction is a very inconvenient complication, because it must 
be overcome temporarily at least before our applications can be made 
complete. 

In this form I have frequently succeeded by using the slippery elm 
tent. The tent can be made to overcome the stenosis and at the same 
time exert a salutary influence by pressure upon the mucous mem- 
brane of the uterine cavity, and thus suffice to effect a cure. 

The slippery elm tent is made about one inch and a half, or one 
and three-fourths long, and the sixth of an inch in diameter at the 
large extremity, and small enough at the other to pass through the 
narrowest place. Every tent should be securely fixed by threads so 
that it cannot be lost in the cavity, and may be easily removed. 



TREATMENT OF ENDOMETRITIS. 



325 



When \N'e use them we thorouglily moisten them for two-thh'ds 
the distance from the extremity to be introduced. This moistening 
may be done in a moment by dipping them into water and then 
pinching and bending them. 

The part thus moistened should be soft enough to bend in any di- 
rection with very sb'ght force. AVhen the cervix is exposed we take 



Fig. 95. 




Slippery Elm Tent. 

the dry end of the tent in our dressing forceps and pass the moistened 
end into the uterus. The pliability of the tent enables us to pass it 
easily into the most tortuous canal. After having passed one, if we 
are not satisfied, we may intro<:luce one by the side of it, and then 
two, three, four* or a dozen until we have dilated the canal suffi- 



326 



LOCAL TREATME^'T. 



cientlv. These mav be allowed to remain several hoars if necessary, 
to cause further dilatation. Bat often they may be removed at once, 
and the cervix will be large enough to receive an application. I 
know, however, from frequent trial that no other application is nec- 
essarv to cure many cases of endometritis. 

When I introduce one or two tents, in cases where stenosis com- 
plicates endometritis, I instruct the patient to remove the tent by 
drawing upon the thread whenever it gives her decided pain, and to 
not let it remain more than twelve hours if it does not give her pain. 

Fig. 96. 




Slippery Elm Tent introduced. 

This is by far the most comfortable way of dilating, and according 
to my observation the most effective. The slippery elm has the ad- 
vantage of being inexpensive and easily procured. In ten minutes 
the practitioner can make a dozen with his pocket-knife, out of the 
dry bark found in any drug store. AVhen used in this way, and for 
this purpose, the dilatation is very moderate, but by repeating it be- 
comes jjermanent more readily than by the use of any other means. 
I can say further that I have had no bad results from slippery elm 
tents when used in this way, and in those exceptional cases alone 
where a mere touch of the probe is painful do I apprehend the pos- 



TREATMENT OF ENDOMETRITIS. 



327 



sibility of harm. It is the safest means to dilate the cervix now in 
use, and when several are introduced by the side of each other they 
may be made to dilate the cervical cavity in a few rainute?>. 

This tent also may be made to shield the cervix from the eflPects of 
the pressure of the more energetic dilators. If we wish to dilate 
the cervix largely we may pass a sea-tangle or sponge tent, and then 
jQll the cervical cavity around it by slippery elm tents. 

As the sea-tangle or sponge expands, the elm tents shield the deli- 
cate mucous membrane from contact with the hard tent, and when 
the time comes to remove it there will be no difficulty in getting it 
away. Complicating misplacements, especially retroversions, should 

Fig. 97. 




The rterus in a state of Anteflexion, with, the Slippery Elm Bougie introduced into it. 

be corrected as an indispensable item of treatment. After the cor- 
rection is made the treatment will not differ in any respect from the 
uncomplicated case. 

Flexions are more embarrassing, complications than displacements, 
because the point of greatest flexion is stenotic. Sometimes the ste- 
nosis is so great that it is difficult to pass a small sound. (Fig. 97.) 
The correction of the complication and the treatment of the inflamma- 
tion may both be accomplished at the same time. These are the cases 
ill which the slippery elm tent will be of the greatest service. They 
are often attended with the dysmenorrhoea of obstruction. We can 
dilate and, to a certain extent, correct the flexion every time we make 
an application, by using one or two elm tents before introducing the 
application. But generally the tents, if allowed to remain in the 



328 LOCAL TREATMENT. 

cavity, as directed in the treatment of stenosis just described, will 
exert a salutary effect by pressure. 

When the practitioner finds that a pessary can be used to advantage 
it may be employed at the same time with the other treatment. 

When complicated by menorrhagia both diseases may generally be 
cured by the curette used as above directed. 

I have said nothing about intrauterine injections as a means of 
curing endometritis. The subject has been very thoroughly discussed 
by the members of the profession, and few prominent gynsecologists 
resort to this means in any form or at any time, except in the puerperal 
condition of the organ. For my own part I have never injected the 
uterus for endometritis, and I do not hesitate to condemn it in such 
cases as dangerous, and yet there are those for whose opinions I have 
the highest respect, who advise and employ injections, and speak of 
them as the most efficacious of all methods of applying medicines to 
the interior of the uterus. 

Professor James P. White,* of Buffalo, has invented a pipette of 
glass, bent to the shape of the uterus, with a bulb of india-rubber at 
the external end. He dips the end of the tube, which is very minute 
in size, into the fluid he desires to use, and then passes it through 
a speculum into the uterine cavity, and presses out in drops, or as 
much as he desires to leave there. The small quantity thus intro- 
duced he claims cannot, and does not, give rise to any grave symp- 
toms. 

In discussing the paper thus referred to, Dr. Munde, of New 
York, said : That he applies fluids to the cavity of the uterus through 
a very small flexible tube invented by Dr. Buttles, of New York. 
He thinks, cautiously done, this is a safe and efficacious way of treat- 
ing the interior of the uterus. This method of using fluids in the 
cavity of the uterus can hardly be classed among injections, as the 
term has been heretofore understood. 

* Paper read before the American Gynecological Society, 1879. 



I 



CHAPTER XIX. 

LACEKATIOXS OF THE CERVIX UTERI. 

The consequences of this accident are so serious, and its occur- 
rence so frequent, that it demands a prominent place in any text- 
book on gynaecology. 

While many observers had noted the presence of lacerations of the 
cervix uteri, their importance until lately has been underrated; 
they were thought, in fact, to give rise to no appreciable effects. 

This view was encouraged by the fact, that a proper treatment of 
their consequences generally resulted in a temporary removal of the 
symptoms, and sometimes the cure was so nearly complete as to pass 
for an entire recovery. 

Until Dr. Emmett made his remarkable researches upon the sub- 
ject, lacerations of the cervix passed for one of the forms of ulcera- 
tion, and was described as ulceration of the cervix uteri. Xow, how- 
ever, owing to the enthusiasm of the discoverer, many of his students 
have gone to what I consider an unjustifiable extreme in the other 
direction, expressing their opinions that, instead of everything being 
called ulceration, the proper term will be laceration of the cervix. 

To Dr. Emmett belongs the credit of first appreciating the im- 
portance and appropriately treating this accident. 

It very seldom occurs to any man to have the opportunity of 
giving to the profession so complete a description of an abnormal 
condition, and to perfect the process of cure, so that there is left to 
others no room for improvement. Yet this is the good fortune of 
Dr. Emmett. 

Causes. 

Laceration of the cervix occurs during labor or expulsion of the 
contents of the uterus in abortion. Sudden expulsion of the head in 
cases where the cervix is not dilated sufficiently may eventuate in 
its rupture. 

It would be foreign to my purpose at present to discuss the vari- 
ous causes of the rigidity which prevents the ready dilatation of the 
cervix. They certainly are numerous, and of frequent occurrence, as 
any obstetric practitioner is aware. ]Xor do I consider it necessary 
to criticise the early and frequent use of the forceps practiced by the 



330 LACERATIONS OF THE CERVIX UTERI. 

accoucheur of the present day. The time has not yet come when 
the facts are at hand to justify such criticism. It is in order, how- 
ever, to inform the obstetrician that his patients come to the gynsecol- 
ogist with laceration of the cervix in great numbers. Dr. Emmett 
finds laceration in about 16 per cent, of the cases coming to him for 
treatment on account of uterine disease. Dr. Munde puts them down 
at about 17 per cent. Dr. Montrose A. Fallen at 40 per cent., 
and Dr. Goodell says, one in every six of his dispensary patients has 
laceration of the cervix. My own observation confirms the opinion 
that these lacerations are of very frequent occurrence. Observing 
the difference in virgin, as compared to the parous uteri, one must 
conclude that slight laceration from labor was the rule. 

Can extensive laceration of the cervix always be avoided? This 
question brings to mind the frequency with which the perinseum is 
torn under the management of the best practitioners, and the univer- 
sality with which slight laceration of that body takes place in primip- 
arous women. 

The Degree, Locality, and Direction. 

The degree of laceration varies from the slight, almost inappreci- 
able rupture to the splitting of the cervix into and above the vaginal 
junction. It may be confined to one side, while the other retains its 
integrity, or both sides may be torn, one slightly and the other largely, 
or both to their utmost extent. 

The locality of the laceration is much more frequent in a line cor- 
responding to the junction of the anterior and posterior halves of the 
cervix, but sometimes the anterior or posterior lip of the uterus is 
torn in the centre in the various degrees above mentioned ; in others 
both the anterior and posterior lips are thus lacerated. In rare in- 
stances we find the two lateral and the two central lesions in the same 
cases, making the cervix project into the vagina with four points. 
I have seen one case where the anterior lip was split up to the vagi- 
nal junction, and then torn across to the left side, the portion torn 
hanging down into the vagina. 

Dr. Emmett thinks that the anterior and posterior labia are fre- 
quently torn, but from the direction of the vaginal pressure they 
generally heal up, and consequently do not often come under our 
observation. It is not unlikely, as he observes, that many lateral, 
as well as central, lacerations close up during the term of lying in, 
and therefore never give rise to any inconvenience. 



EFFECTS ON THE BODY OF THE UTERUS. 331 

Effects of the Laceration. 

If we were guided by what we know of traumatic lesions elsewhere, 
as well as what we find in the cervix itself, we would, a priori, infer 
that inflammation was an early consequence of the accident. 

The torn edges, much more frequently than otherwise, become 
covered with cicatricial tissue, the result of inflammatory exudation, 
and a large amount of this cicatricial deposit is ordinarily found in 
the angle of the laceration. Sometimes this last point of deposit 
presents a tough, hard node, that must be removed with great care 
to secure perfect union. 

This is not all the effects of the inflammatory action. Sometimes 
a fibrino-plastic exudation in the connective tissue of the two cervi- 
cal flaps takes place, and they become large, dense, and hard. 

The surgeon will often find the cervix indurated so greatly that it 
resists the instruments, especially the passage of the needles ; and he 
will find, as a rule, the more extensive the laceration, the greater will 
be this particular change, showing that they are all the seat of the 
most intense inflammatory action, and the converse. 

Another efi'ect of the laceration on the parts is, at first, an inflam- 
matory action in the mucous membrane of the cervical cavity. 
Fibrino-plastic deposits occur in the deeper portions of the mem- 
brane, which becomes turgid and redundant; its epithelium is shed, 
and it presents a scarlet, rough surface. Sometimes the redundancy 
of the membrane is so great that it rolls out and forms a mass, fun- 
giform in appearance. 

As another consequence of this fibrino-plastic exudation, the mouths 
of many of the ducts leading from the glands of Naboth are closed, 
and the mucus of the glands is confined within their cystic cavities, 
or the whole gland is surrounded by the exudation and becomes in- 
volved in the hardened mass. Thus, in diflerent cases, we find the 
glands presenting the appearance of translucent blebs or shotlike 
granulations. 

Effects on the Body of the Uterus. 

The inflammatory process going on in the cervix, resulting from 
lacerations, arrests involution, and the uterus remains large and vas- 
cular; in other words, in a state of subinvolution until the chronic 
inflammation is removed by proper treatment of the mucous mem- 
brane and submucous tissue, and the laceration closed by trache- 
lorraphy. 

That lacerations which do not cause and maintain this uterine 



332 LACERATIONS OF THE CERVIX UTERI. 

hypersemia are innocent of general disturbances, is admitted by Dr. 
Emmett, as I have shown elsewhere by quotations from his work.* 

Complications. 

Other embarrassing complications of laceration of the cervix are 
displacements, prolapse, and retroflexions, and lacerations of the peri- 
nseum and vagina, and cellulitis and local peritonitis. These com- 
plications increase the hypersemia of the uterus, — retroflexion, by 
constriction of the cervix and consequent turgescence of that portion 
of the uterus with this; and prolapse, by altering the direction of 
the veins which carry the blood from the uterus, augmenting the 
previously existing hypersemia of that organ. The uterus is thereby 
increased in weight, fibrino-plastic changes produced in its substance, 
and the nutrition of the mucous membrane of its cavity disturbed in 
a marked degree. 

Symptoms. 

The general symptoms following laceration of the cervix are not 
distinctive. That lesion produces, through its effects upon the body 
and cervix uteri, the symptoms given in detail elsewhere, under the 
head of Hysteropathy, and consequently need not be repeated here. 

Diagnosis. 

This cannot be made out by subjective symptoms alone, and we 
must depend upon a thorough examination of the parts by the touch 
and use of instruments. By careful examination with the finger the 
notch in the side, when large, will be easily detected. The finger 
should pass along the vaginal wall to its junction with the cervix, 
and, keeping it in the cul-de-sac, passed all around so as to encircle 
the neck. 

In most instances, as the finger passes over the side, we will rec- 
ognize the fact that at that point the neck does not extend below the 
vaginal junction. The finger will sink into a depression between 
the labia. 

When the finger is educated in the vaginal touch, the lesion will 
be easily recognized. 

The sound will generally pass deeper into the body of the uterus 
than it will in the normal state of that organ, because the uterus is 
in a state of subinvolution. 

■* Article on Subinvolution. 



PREPARATORY TREATMENT. 333 

AYhen well exposed by the speculum, the cervix will generally be 
found covered by a muco-purulent fluid, enlarged, the labia turned 
out, the exposed cavity of the neck intensely red, and the surface 
roughened in consequence of the loss of epithelium, and an enlarge- 
ment of the papillae and muciparous glands. The infallible test, 
however, is to seize the extremities of both labia with tenacula and 
draw them down together, somewhat forcibly. If the cervix has 
been torn on the side, the notch will be plainly seen. If there is no 
laceration, the cervix will be truncated instead of bifid, and the points 
of the tips can be drawn down only a trifling distance below their 
lateral junction. 

Treatment. 

The treatment may be preventive, preparatory, and operative. 

The prevention of laceration of the cervix does not usually come 
"within the province of the gynaecologist. The obstetrician has charge 
of the patient at the time of the accident, and upon his skill will de- 
pend such immunity as can be secured by science. The probability 
is that it cannot be prevented in most instances in which it occurs, 
no more than laceration of the perinaeum can always be prevented. 
I can easily see how an early rupture of the membranes, a too early 
use of the forceps, or an ill-advised administration of ergot would 
favor laceration of the cervix. 

Now that their attention is called to the subject, obstetricians will 
no doubt soon be able to furnish the facts upon which may be based 
a judicious preventive treatment; at present it must be founded 
upon a rational view of the processes of labor. 

Preparatory Treatment. 

The treatment preparatory to an operation has been as fully devel- 
oped by Dr. Emmett as any part of the subject, and my experience 
corroborates the correctness of his teachings. 

The object of the preparatory treatment is to bring about a plastic 
condition of the parts to be united. This is accomplished by correct- 
ing any deviation from the normal state of general health by tonics, 
nutritious diet, exercise in the open air, promoting a soluble condi- 
tion of the bowels with appropriate laxatives, etc. 

A robust state of the general health is an all-important part of the 
preparation in this as in all plastic operations. 

The local preparatory treatment consists, first, in placing the uterus 
in such position as is necessary to secure the greatest possible freedom 



334 LACERATIONS OF THE CERVIX UTERI. 

of circulation, for the purpose of reducing the general hypersemia of 
that organ ; second, ruaking use of such applications as will reduce 
the hyperseraia of the uterus and cervix ; and, third, where there is 
induration from fibrino-plastic exudation in the connective tissue of 
the cervical flaps to as far as possible dissolve it out and bring about 
a normal condition of the structure. 

The first indication is met by a judicious use of pessaries of 
cotton, lint, and the closed-lever instrument.* The second, calls for 
the use of glycerin, cotton tampons, local bloodletting by puncture 
w^ith Buttle's lancet-shaped knife, or other instrument, which will 
answer the same purpose, and large hot-water injections. An em- 
ployment of these means perseveringly for a sufficient length of time 
will be pretty sure to effect this object. The third will generally re- 
quire more time, and is of equal importance with the other two. 
The applications for this purpose consist in remedies that will stimu- 
late the absorbents to the removal of the indurating substance. Dr- 
Emmett relies to a great extent upon Churchill's tincture of iodine 
for this purpose. He applies it freely to the whole of the denuded 
mucous membrane about twice a week, followed by glycerin dress- 
ings. It is doubtless an excellent application. 

When the gland cysts are large and numerous he pricks them with 
the lancet-shaped knife to void their contents and to deplete them of 
blood. 

In many cases of long standing, and w here the pathological changes 
are greatest, the preparatory treatment will require to be employed for 
several months to secure the best results. In others of recent stand- 
ing, and wdiere the changes consist mostly of hypersemia a few weeks 
will suffice. 

The Operation. 

The day before the operation it is a common practice, and I think 
a good one, to move the bowels pretty thoroughly by giving a laxa- 
tive. At the time of the operation I usually give the patient ether. 
This, how^ever, is not absolutely necessary, especially in cases of mod- 
erate extent, as the operation is not very painful. 

To Dr. Dudley, of this city, is conceded the honor of first giving 
this operation an appropriate name, '^trachelorraphy.'^ Tw^o or three 
days after the menses cease to flow is the best time to operate. 

The patient is placed in Sims's or Simon's position, and the vagina 
dilated as largely as necessary to bring the cervix into view. The 

* See Displacement. 



THE OPERATION. 



335 



neck is then seized with a vulsellum forceps, and drawn down until 
the lips can be transfixed from before backward by a strong needle 
armed with a double thread. 

The threads are drawn through enough to form two loops, each 
through one of the labia, of sufficient length to pass several inches 

With these loops of thread the cervix can 



out of the vaginal orifice. 



Fig. 




The Cervix with the Threads passed. 



be very completely fixed, and its position varied as- the convenience of 
the operator may require. The loops of thread may be held up by 
an assistant, subject to the direction of the surgeon. 

When thus prepared the operator seizes the edge of the laceration 
with a tenaculum, and with scissors pares oif all the cicatricial mem- 
brane. The denudation should be carried up into the angle between 
the cervical flaps and the wedge of cicatricial deposit thoroughly re- 
moved. In doing this care should be taken to cut off any irregu- 
larity of surface on the edge of the laceration, so that the edges of 



336 



LACERATIONS OF THE CERVIX UTERI. 



the two sides may be brought into smooth coaptation. After the de- 
nudation is perfected, and the haemorrhage ceases, the stitches may be 
introduced. Beginning an eighth of an inch from the incision on 




Dr. Sawyer's Round Knife for Denuding Surface. 

the outer surface of the flap, the needle is passed perpendicularly 
through to a point that will include the same distance of the endo- 
cervical membrane. To the thread in the needle should be attached 



Fig. 100. 




Byford's Uterine Scissors. 

silver wire eight or ten inches long, drawn through and held by an 
assistant, until all of the wires are placed as in Fig. 101. Before 
twisting the wire the edges of the wound should be wiped clean of 
every small coagulum. 

If this precaution is not taken a clot of blood may be included 
between the united edges and prevent complete union, the wires may 
then be twisted evenly, as represented in Fig. 102. After the opera- 
tion the vagina should be thoroughly cleansed and the patient put to 
bed. 

This operation is a simple one, as the reader will see, under favor- 
able circumstances, i. e., when the laceration is lateral, and does not 
extend above the vaginal junction. When it is stellate, or there is much 
loss of tissue, the ingenuity of the surgeon will be severely taxed. 

I am not informed as to the average number of successes in the 
operation of trachelorraphy, but I know that failures are not infre- 
quent, and it may be well to consider what are the reasons of failure. 

Among these reasons is an imperfect performance of the operation, 
but chief among them is imperfect preparation. 



THE OPERATION'. 



337 



The after-treatment is of great importance, especially for the first 
few days. The patient must remain very quiet and avoid all causes 



Fig. 101. 




Tlie Mode of Passing the Sumres. 
Fig. 102. 




The SnUires Properly Placed and Sutured. 



338 LACERATIONS OP THE CERVIX UTERI. 

of vascular and nervous derangements. After this time there can 
be more freedom of motion. It is desirable that the bowels be not 
moved before the end of this time, when a laxative may be given, and 
means taken thenceforward to keep them in a soluble condition. If 
we do not conclude to prevent the evacuation of the bowels we should 
administer diet and saline laxatives to soften the faeces. 

It has been usual to draw off the urine for the first four or five 
days, but this is not essential, as it is only necessary to avoid strain- 
ing. 

The diet must be light, and for the most part liquid, for the first 
few days. 

The vagina should be kept clean by warm-water injections two or 
three times a day from the beginning to the end of the after-treat- 
ment. I have been in the habit of removing the sutures about the 
tenth day, but in the majority of cases they might be taken out on 
the seventh or eighth day. 



CHAPTER XX. 

OCCASIONAL UNTOWARD EFFECTS OF UTERINE MANIPULATIONS 
AND OPERATIONS. 

For the purpose of making the student understand the necessity 
of great caution and gentleness in examinations and operations upon 
the uterus, I subjoin a summary of the researches of Dr. George J. 
Engleman, of St. Louis, on the subject.* 

Many of the cases mentioned by Dr. Engleman occurred in the 
hands of the most accomplished practitioners in different parts of the 
world. A simple digital examination of the unimpregnated uterus, 
in the hands of Nelaton, was followed by fatal peritonitis. 

Several cases of death from peritonitis were the result of the use 
of the uterine sound ; some because the sound perforated the uterine 
tissues on account of fatty degeneration rendering them soft and 
permeable ; others without any apparent reason. 

There are also cases in which untoward results followed the use of 
vaginal injections of warm water. 

A number of deaths are recorded in which peritonitis was caused 
by the use of sponge tents. One case is mentioned of severe peri- 
tonitis from replacing the uterus by the use of the sound. There is 
always more or less risk in this operation. Dr. J. M. Allen gives a 
case in which death was caused by the appplication of tincture of 
iodine to the cervix. 

Cellulitis has followed the application of various substances to the 
cervical and uterine canal. 

The danger of injections into the uterine cavity is shown by allu- 
sion to several cases of death in the hands of skilful gynaecologists. 
The most trivial operations on the uterus or other organs in the 
pelvic cavity are sometimes followed by fatal results. Even scarifi- 
cation of the cervix has been the cause of fatal peritonitis. 

I have known of two cases of death follow incision of the cer- 
vical canal, and several others are mentioned in Dr. Engleman's 
paper. Operations for lacerations of the cervix have been followed 

■^ Paper read before the Missouri Medical Society, and published in September 
No., 1880, American Practitioner. 



340 UTERINE MANIPULATIONS AND OPERATIONS. 

by deatli in several instances. The most careful removal of small 
polypi may be the cause of fatal peritonitis. 

Perineorrhaphy has, in a number of instances, been followed by 
similar consequences. Stem pessaries, when incautiously used, are 
very dangerous instruments. 

It therefore a2:)pears that any kind of manipulation of the uterus or 
its lining membrane is, under certain inscrutable circumstances, 
liable to start an acute peritonitis. One of these circumstances, and 
perhaps the most frequent one, is the existence of an inappreciable 
grade of inflammation in the cellular or peritoneal structures imme- 
diately surrounding the uterus. 

Dr. ^oeggerath"^ believes that latent gonorrhoea is very often the 
character of this lurking inflammation. 

It would seem that the use of sponge tents, intrauterine stem pes- 
saries, intrauterine injections, intrauterine applications, and cutting 
operations on the cervix uteri, were especially dangerous. 

AVe should exercise great care in all our manipulations of the 
pelvic organs, and leave no precautions known to gynsecology unem- 
ployed to avoid the dangers that occasionally present themselves 
when we venture upon the use of sponge tents, intrauterine injec- 
tions, stem pessaries, or operate on the cervix. 

* Gynsecological Transactions, 1876. 



CHAPTEE XXI. 

HYPERTEOPHY OF THE CEEYIX. 

Hypertrophy of the cervix is different from enlargement caused 
by fibrinous accumulation, and consists of an increase in the proper 
tissues of the organ. It is a real hypertrophy. Although not nearly 
so frequent as the enlargement from chronic inflammation, it is not 
of very rare occurrence. The symptoms do not differ from prolapse 
of the uterus sufficiently to characterize it. The patient generally 
experiences a sense of bearing-down or weio^ht on the perinteum, pain 
in the sacral region, leucorrhcea, sometimes menorrhagia, and the 
various sympathetic symptoms already sufficiently dwelt upon of 
uterine irritation. 

Diagnosis. 

Upon examination the cervix is found hypertrophied and enlarged. 
There are two general forms observed so well marked as to entitle 
them to special mention. The first is such as we usually find in the 
nulliparous, an elongation of the whole cervix, and some, but not 
generally, very great circumferential increase of size, and without 
much deviation from shape. This form is seen in Fig. 103. The 
next variety is an elongation and enlargement of the anterior or pos- 
terior labium, as represented in Fig. 104. I am not certain, from 
my own observation, whether this is always a pure hypertrophy or a 
mixture of this process with fibrinous infiltration ; probably the latter. 

The only appropriate treatment is amputation, and it is generally 
sufficient to remove all the disagreeable symptoms resulting from it. 
The plan I have usually pursued in removing this growth is by 
ecrasement. The chain of the ecraseur is passed around, at the place 
where the point marked out by the dotted line is seen in the figures, 
and the ratchet slowly worked until the division is complete. This 
operation is easily performed, and is perfectly safe when carefully 
done, and the parts cicatrize in a few days. An inconvenience men- 
tioned by Dr. J. Marion Sims is encountered, in some instances, in 
amputating the first variety, viz., the contraction of the opening of the 
cervical cavity. It is an inconvenience, however, that is of no great 
importance generally, and may be remedied by making a small in- 



12 



HYPERTROPHY OF THE CERVIX. 



ci^ion with a blunt-pointed bistoury immediately after the operation 
of amputation. Dr. Sims amputates the cervix with scissors. He 
exposes the organ with his speculum, cuts the parts squarely through 
at the dotted lines, and then draws the mucous membrane together 



Fig. 103. 



Fig. 104 





Figures showing two Varieties of Hypertrophic Elongation and Enlargement of the Cervix 
Uteri. The Dotted Lines show the Proper Place for Amputation. 



over the cut surfaces with silver sutures. This lessens the size of the 
cut surfaces and the parts heal more readily. 

Elongation of the Supravaginal Cervix. 

This condition of the cervix so completely simulates procidentia of 
the uterus that upon a superficial examination it may be mistaken 
for that condition. The elongated vaginal cervix w'ith the vagina 
are protruded from the external parts. The vaginal walls are everted 
anteriorly and posteriorly, forming in most instances cystocele and 
rectocele. Sometimes the protrusion is less extensive, and the cervix 
alone protrudes from the external parts. 

The diagnosis is made by introducing the sound. That instru- 
ment will enter to a much greater depth than when the uterus is pro- 
lapsed, sometimes five or six inches. 

2d. By placing the patient in the knee-chest position. In this 



ELONGATION OF THE SUPRAVAGINAL CERVIX. 



343 



posture the cervix very readily enters the pelvis and rises up to its 
normal position. If the sound is now introduced it will not enter 
the uterus to so great a depth. 

3d. By introducing the finger into the rectum while the patient 
is standing, we can feel that the length and shape of the uterus are 
greatlv chano^ed from the normal. The fundus and bodv will be 
found in situ, and from it the attenuated and elongated supravaginal 
cervix can be traced downward to its attachments to the vagina. 

Fig. ia5. 




Supravaginal Elongation of the Cervix. 

This elono;ation of the cervix is called tensile elono-ation bv Dr. 
Matthews Duncan, and, doubtless, as Dr. Goodell'*' believes, is the 
result of hypertrophy and stretching, instead of true hypertrophy. 
It would seem at any rate that the elasticity of the cervical tissues was 
very much increased, as in the erect posture, with the slight weight 
of the relaxed vaginal walls and the bladder and rectum, the neck 
becomes elongated, and when the patient lies down retraction may 
soon follow. 

The vaginal portion of the cervix in most cases is considerably 
hypertrophied, and in respect to length and volume is much above the 
usual dimensions. There are other conditions in connection with 
tensile elongation of the cervix that have an important bearing upon 

* Gynaecological Transactions, 1879. 



344 HYPERTROPHY OF THE CERVIX. 

the etiology and treatment. Almost all the means of siippoit in the 
lower part of the pelvis are in a state of great relaxation, and, instead 
of being retentive, they contribute to the aggravation of the ab- 
normal condition of the cervix. 

This is especially the case with the vaginal walls, the vesical 
ligaments, connective tissue, and fascia. 

The perinteum is either anatomically deficient from laceration, or 
destitute of that tonicity which makes it capable of resisting tlie pro- 
trusion of the cervix. In contrast with this the supporting apparatus 
in the upper part of the j>elvis retains its natural, if it is not endowed 
with more than normal retentive power. 

The treatment of this form of elongated cervix will depend some- 
what upon the time it has lasted, the extent of the elongation, and the 
relaxation of the perinseum. 

When the lesion is of recent origin, and the perinaeum has not been 
lacerated, and possesses a reasonable amount of resistance, we may 
hope to succeed in restoring the shape and size of the cervix by prop- 
erly supporting it with a pessary. In selecting an instrument for 
this purpose it will not often do to choose one that has its bearings 
wholly upon the perinseum, but one that is partially maintained in 
position by external means. 

In the hands of most practitioners, I believe Cutter's or Scott's 
will fulfil the purpose more certainly than any other. ^Vhile both of 
them rest upon the ferinseum they may be so adjusted that they will 
not bear upon it with much weight. If, however, the perinteum is 
in a lacerated or greatly relaxed state we must depend mainly upon 
surgical means, and as the result of my own observation, I do not hesi- 
tate to indorse the practice of Goodell as set forth in the paper above 
referred to, viz., to amputate the vaginal cervix and operate upon 
the perinaeum afterward if necessary. I do not consider it necessary 
to remove the cervix at the vaginal attachment, but think it better 
to leave a margin of one-fourth of an inch. Great care is necessary 
in removing the cervix in this condition to avoid wounding the blad- 
der or opening the peritoneal cavity. 

Whether the amputation is done with scissors, knife, galvano- 
cautery, or ecraseur, we should take measures to secure ourselves 
against this accident. The most convenient way to do this is to 
pass two strong steel wires through the cervix slightly below the junc- 
tion of the vagina and cervix. The wire or chain of the ecraseur 
may be applied close up to this wire; this will prevent any traction 



ELONGATION OF THE SUPRAVAGINAL CERVIX. 345 

upon one part more than another. The scissors may be used and 
the cervix amputated according to the method of Dr. Sims. The 
patient must remain in bed several weeks to secure the best results. 

When the perinaeum has been lacerated perineorrhaphy should be 
performed before the patient attempts to exercise on foot. 

If the perineum does not need restoration, and there should be any 
tendency to continuance of supravaginal elongation after the opera- 
tion, Scott's pessary should be introduced, to supply the support 
that the perinjeum in a healthy condition would give. 

Success in this operation will depend very greatly upon the treat- 
ment and care the parts receive for some time after the patient 
resumes the erect posture and her usual exercise. 



CHAPTEE XXIL 

PEKIMETEITIS. 

I USE the term perimetritis to signify inflammation of the tissues 
surrounding the uterus, and include both cellulitis and local perito- 
nitis under this head. 

There is an abundance of areolar tissue in the pelvis. It is be- 
tween the bladder and pubis, the bladder and vagina, the vagina and 
rectum, but in greater amount between the sides of the vagina, uterus, 
and bladder, and the pelvic bones. In a loose manner it fills up the 
space indicated, and is covered by, and included in, the folds of the 
lateral or broad ligaments of the uterus. Within these folds of the 
peritoneum, the ovaria, the Fallopian tubes, and the round ligament 
are included with the cellular tissue. Inflammation attacks this areo- 
lar tissue not unfrequently on one side, and involves the tube, the 
ovary, ligament, and peritoneal covering; less frequently both sides 
are simultaneously inflamed, and still less often that part between 
some of the hollow organs of the pelvis is affected, when we have a 
comparatively small point of disease, as, for instance, between the 
bladder and vagina, or this last and the rectum. This is perimetritis. 
There is a strong tendency when inflammation is lighted up in any 
part, to spread to the space at the side of the uterus and vagina cov- 
ered by the broad ligament, on one or both sides. The inflammation 
is apt to run its course rapidly, as is usual in areolar tissue, either to 
resolution or suppuration, and as this tissue is abundant, and the 
organs in the pelvis easily moved, the effusive products are likely to 
be copious. In the first stage of inflammation, serum is rapidly 
poured out between the folds of the peritoneum by the side of the 
uterus and vagina; it pushes these organs to one side of the pelvis, 
and forms a prominent inflammatory tumefaction at the side of the 
pelvic cavity, within easy reach of the finger. This tumidity becomes 
harder in a short time, and forms a solid medium of connection be- 
tween the uterus and wall of the pelvis. Indicating the change from 
serous to fibrinous effusion. Within a week or ten days, in very 
acute cases, in others from two to four, or even six weeks, the areolar 
tissue is broken down into copious suppuration. In some instances 
the inflammation does not advance beyond the stage of serous effusion. 



CELLULITIS. 347 

When, after lasting for an uncertain time, the symptoms begin to 
subside, the tumefaction disappears, and the patient soon recovers her 
health; while in others it is arrested after fibrinous infiltration has 
cemented the parts solidly together. Although the symptoms are 
moderated from their first acuteness when this is the case, some of 
them, as undue seusititiveness and sense of weight, and other kinds 
of pelvic distress, remain for a considerable time, and the patient re- 
covers from the attack very slowly, if ever completely. When sup- 
puration takes place, if it is completely and readily evacuated, the 
patient very soon regains her health and strength. In some patients 
of broken-down or damasked constitutions, slouo^hins; and extensive 
ulceration increase the damage to the organs. I once saw a syphilitic 
patient in whom extensive and rapidly spreading ulceration opened 
the rectum, vagina, bladder, and, finally, the peritoneal cavity. Sup- 
puration in this case was unhealthy and ichorous, smelling strongly, 
and produced excoriation of the parts over which it flowed. If the 
evacuation of the pus is imperfect on account of opening into the 
rectum or bladder, and even in the vagina, the symptoms may be 
prolonged for months and even years. And in some cases where the 
evacuation of the pus and subsidence of the inflammation seemed 
complete, the disease recurs usually with diminished acuteness a num- 
ber of times. I once had a patient in whom an attack of perimetritis 
was contemporaneous with incipient pregnancy for four different times 
while under my care. In each one of these four times, the inflam- 
mation commenced at about the time the menstrual flow ought to 
have appeared after conception. Every time there was copious sup- 
puration, a free discharge of the pus, and, to all appearance, a com- 
plete recovery from the inflammation. The intervals were about two 
years in duration. I have seen three instances in which the recurrence 
of the inflammation had occurred at irregular intervals from three 
months to a year for over six years, another ten, and one as much as 
eighteen years. In this last case, the abscess was situated at the left 
side of the uterus, and usually after a week or ten days of acute suf- 
fering, it discharged about a half ounce of fetid pus, and then disap- 
peared, so that nothing but a slight induration at the point mentioned 
indicated any tendency to its recurrence. This chronic form, I think,' 
is not very uncommon. I believe, also, that chronic induration in 
the spaces occupied by the pelvic areolar tissue, caused by fibrinous 
infiltration, not unfrequeutly presents itself as the effect of acute peri- 
metritis, producing many distressing symptoms, and rendering the 
patient liable to a recurrence of acute attacks. The extent of the in- 



348 PERIMETRITIS. 

flammation and tumefaction is governed somewhat by the condition 
of the patient. If she be in the puerperal state, the inflammatory 
excitement is likely to be greater, the swelling more extensive, and 
the suffering more severe, than if this condition is not present. Preg- 
nancy increases the intensity of the disease beyond what it is in the 
unimpregnated condition; the fever runs higher, and the extent of 
the inflammation is greater. The same will be the case after abor- 
tions. The mildest form of perimetritis is that which occurs in the 
unimpregnated female. 

When pus is formed, it finds its way out through several different 
channels. First, and most frequently, through the vagina; the wall 
of the abscess nearest the vagina ulcerates through into this canal, 
and the pus escapes, first in small Cj[uantities, and finally freely, until 
the whole is evacuated; a number of days, and even w^eks, may 
elapse before the discharge ceases and the cavity is filled up. The 
escape through the vagina is not only the most common, but this is 
the most favorable outlet, as the opening is generally pretty free and 
permanent. Second, in frequency, as the medium of discharge is the 
rectum; the pus makes its way into this intestine generally at the 
upper end of the septum between it and the vagina. The discharge 
is comparatively slow and unsatisfactory, appearing with the stools 
in small quantities, and continuing for a length of time. The open- 
ing into the bowels is almost, if not invariably, valvular and tortu- 
ous, permitting the escape with difficulty. If there does not occur a 
second opening into the vagina, the abscess will generate pus almost 
as fast as discharged, and we may expect times of partial relief and 
exacerbation for months and even years. I am acquainted with an 
instance in which the patient has not been entirely free from suffering 
from this cause for the last six years, and a number of times has been 
prostrated for weeks. But few days pass without the patient observ- 
ing matter in the fecal evacuations. The pus makes its way at other 
times through the inguinal regions; sometimes it points in one of the 
labia, or burrows through the gluteal region. It also perforates the 
uterus or bladder, and follows the channels leading from them out- 
wardly. When the pus finds its way into any of these hollow organs, 
it causes severe irritation in them and efforts at expulsion. Dysuria, 
dysentery, and vaginitis are generally caused by it to a moderate de- 
gree, but sometimes the suffering from this cause in these organs is 
very great. But another mode of escape from the cavity of the ab- 
scess is into the peritoneal sac. This is comparatively infrequent, 
fortunately, but invariably fatal. I believe no instance is on record to 



CELLULITIS. 349 

coDtradiot this statement. I have been unfortunate enough to be con- 
nected witli two cases in whicli this untoward circumstance occurred. 
One of the patients was attacked in the puerperal state, and, after 
suffering for eight weeks with the inflammation of the tissues around 
the uterus, acute general peritonitis terminated her life in about 
thirty-six hours from the time it commenced. Upon examining the 
abdominal cavity, an opening was found near the left vSacro-iliac 
junction, which communicated with the interior of the abscess, and 
several ounces of pus was in the cavity of the peritoneum, that had 
made its way through this opening. The usual lesions of extensive 
and acute peritonitis gave evidence of the cause of death. The other 
case was in a sterile marrieil woman, about twenty-live years of age, 
who had been treated three weeks for typhoid fever. Dissection 
revealeil a large pelvic abscess, with recent rupture into the peritoneal 
cavity, and extensive peritoneal lesions. This overwhelming perito- 
neal inflammation lasted only about eighteen hours before the death 
of the patient. When the peritoneal symptom supervened, it was 
regarded as the result of the intestinal ulceration which sometimes 
so suddenly terminates typhoid fever. 

Causes. 
Perimetritis occurs as a sequel to abortions, and labor at full term, 
and there is but little doubt but that these two conditions sometimes 
predispose to the disease. The menstrual congestion seems to do the 
same thing. Any circumstance that fills the pelvis with blood in 
active congestion may so predispose to it. Cold suddenly applied to 
the surface or to the feet and legs may excite the already congested 
parts into a state of inflammation. Much exercise of the limbs in 
walking or standing on them for a long time, when the pelvic vessels 
are already distended and excited, has, on some occasions, seemed to 
me to awaken inflammation. The incautious use of strong caustics 
to the cervix uteri may give rise to it. I think I saw a casein which 
perimetritis was brought about by severe exercise in walking imme- 
diately after the use of caustic potassa. Excessive venereal indul- 
gence predisposes to this inflammation, if it does not produce it 
alone. "^ 

Sy7nptom.s. 

The patient is attacked suddenly, usually with pain in the pelvis, 
hypogastrium, or iliac regions, which radiates to the sacrum, loins, 

* See Chapter XX for other cause. 



350 PERIMETRITIS. 

and alxlomen. Sometimes it passes down one extremity, or there is 
pain in both legs. The pain, generally at first aching and moderate, 
raav become verv severe, and darting or cramping in character. In 
the besrinninor, or after the inflammation has lasted a little while, 
there is pain or difficulty in urinating; by pressiiig upon the inflamed 
parts, the passage of fseoes through the rectum is painful. The pa- 
tient usuallv experiences a sense of weight about the perinseum, and 
dragging in the loins and hips. All the pains are much aggravated 
by motion, or assuming and continuing in the erect posture. Pres- 
sure over the epigastric and inguinal portions of the abdomen in- 
creases the pain and suffering. 

At the commencement of the pain the patient is attacked with 
rigors of greater or less severity. The chilliness may be slight, but 
often it amounts to severe shaking and trembling : reaction propor- 
tionate to the intensity of the chill succeeds ; the head aches, the 
liml3s are pained, the skin is hot and dry. and the tongue coatetl, and 
the mouth dry and parchetl. These symptoms may come on very 
suddenly, and the case be well marked in a few hours from the time 
they commence, or so moderately and gradually as to be several days 
in assuming prominence. In puerperal patients they occur generally 
several days after confinement, and seem to be induced by undue 
exertion or exposure. In such cases the symptoms are more intense 
than in the non-puerperal cases. The pulse is rapid, the nervous 
system much disturbed, the heat great, and often there is delirium. 
The high febrile excitement is attended with severe pain, extending 
in various directions. Tumefaction and tenderness over the lower 
parts of the abdomen indiaite a local peritoneal inflammation in 
many of the more severe instances, although this is not always the 
case. Some of these puerperal cases so closely resemble cases of 
metroperitonitis — if they are not so indeed — that the cases are re- 
garded as attacks of puerperal fever. So intense are the symptoms 
as apparently to jeopardize the life of the patient immediately by 
the gravit\' of the general pelvic and abdominal inflammation. And 
when the tumefaction and tenderness of the abdomen subside, the 
febrile reaction is moderated or becomes more paroxysmal, we find 
a hard tumor generally on one side dipping down into the pelvis 
and extending sometimes to the ribs and across to the umbilicus; 
or it may be developed in the mesial portion of the abdomen and 
pelvis, extending upward to a greater or less degree. Tumors of 
this kind are tender, and may be detected in the pelvis by a vagi- 
nal examination. They do not always suppurate, but generally 



CELLULITIS. 351 

disappear by absorption. At other times they produce copious quan- 
tities of pus. This inflammation sometimes dissects up the peri- 
toneum over the osseous, iliac, and lumbar muscles, to a great extent, 
dissolving out the areolar tissue in a large space. The distension and 
tenderness are quite frequently confined to one side, showing the 
point of greatest intensity of the disease, but we often find them 
extending entirely across, and sometimes considerably up the abdo- 
men. These symptoms appertain to the first stage, and last for from 
four or five days to tvv^o weeks, and in rare cases longer, when they 
are gradually succeeded by those that indicate the suppurativ^e stage. 
The pain becomes less acute, and changes ordinarily to a burning 
character, quite as distressing, if not more so than at first. It is worse 
at night, and prevents the patient from resting. The fever assumes 
something of a remitting type. It is more intense in the evening and 
night ; toward morning a moisture is observed upon the skin, the 
heat becomes less, and there is some amelioration in the suffering. 
After a little longer the paroxysms are very marked; chilliness 
in the afterpart of the day is succeeded by a very rapid pulse and 
intense heat of the surface. This fever lasts for six or eight hours, 
and is resolved by a copious perspiration. These perspirations are 
accompanied with great languor and depression. The patient is de- 
bilitated and much worn by the continuance of the symptoms. At 
length, after days of this exhausting, suppurative fever, the pus 
makes its way through the walls of the abscess, and is discharged 
through some of the outlets mentioned above. If the evacuation is 
free, and the discharge considerable, the relief is very great indeed, 
the fever subsides, the perspiration ceases, the spirits are good, the 
appetite becomes excellent; in fact the change in the patient is very 
great and gratifying. Convalescence is now established, and in a few 
days all the serious and distressing symptoms vanish. If the dis- 
charge is not free, and but a small quantity of the matter escapes, 
although there is relief, it is not so complete. The patient is tem- 
porarily better, but not convalescent. The opening is not sufficient, 
the pus continues to increase and imperfectly discharge, and fluctua- 
tions in the intensity of suffering continue to inspire hope and cause 
depression, until a freer opening occurs in the same place, or another 
one allows the pus to escape more freely. 

This description is intended to apply to cases of considerable in- 
tensity in the puerperal or non-puerperal patient. But the degrees 
of intensity are very different in different instances. Sometimes the 
symptoms are so slight as to scarcely attract attention, until the dis- 



352 PERIMETRITIS. 

charge begins to make its appearance. At other times there is dis- 
tressing fever, but the local symptoms are so poorly marked that the 
case is misapprehended. I have known the fever to last for three or 
four weeks, ending in hectic, with its exhausting accompaniments, 
before the true nature of the case was discovered. 

An example of the occasional insidiousness of the non-puerperal 
form of this affection is exhibited in the following case : 

Mrs. A J aged twenty-four, married two months, has sitfiered 

for the last four years with moderate dysmenorrhoea, and occasional 
leucorrhoea- Sexual intercourse has given her much pain from the 
first since her marriage ; afiter three weeks the pain in the coitus 
became intolerable. At this time she had severe pain in the back 
and pelvic region constantly, but not so severe as to prevent her 
being about in the attention to dom^tic duties and taking a short 
trip by rail with her husband. She had some very slight febrile re- 
action, with sense of chilling, for about twenty da\?, when the par- 
oxysms assumed ^jmething of a hectic character, lasting from three 
o'clock undl seven or eight P.M., terminating with copious dia- 
phoresis. A little later a very severe pain in the hypogastric region 
was developed, attended with frequent efforts at urination. In about 
four days from the supervention of this pain she b^an to pass pus 
in large 'quantiti^ in the urine, together with marked quantities ot 
blood. Upon making examination at this time the pelvis on the 
right side and front portion was filled by a tumefaction very tender 
to the touch, which had crowded the uterus back upon the redtam and 
down so that the os was in contact with the perinseum. These ^mp- 
toms and the examination fully declared it a case of cellulitis. 

Diagnosis. 

Although the symptoms, in most cases, are severe and sufficiently 
prominent, they are not often distinctive. Several other ajlfecdons 
r^emble it in many symptoms. Hence, the only way to arrive at 
correct diagnosis is by physical examinations. The finger will be 
the only instrument nece^ary. It is cruel to use the speculum, 
while it affords us no aid in the vast majoritv of cases. I should not 
think it nec^essary to caution the reader against die use of this install- 
ment if I had not seen it resorted to more than once, to the great 
torture of the patient. In making examinations for this kind of 
case, the patient should be so placed that we may use both hands if 
necessary. When one or two fingers are introduced into the vagina, 
they will detect unusual tumidity in the pelvis. Sometimes this 



CELLULITIS. 353 

tumidity extends to the bottom of tlie pelvis on one side, and occa- 
sionally apparently fills up the \vhole loNver part of the pelvic cavity ; 
at other times the tumidity is circumscribed and confined to one side 
high up, or before the uterus. The tumefied parts are generally hard, 
and very tender to the touch, so that a small amount of pressure 
causes great suffering ; the uterine neck is almost always pushed to 
one side, back\yard, upward, or downward; the vagina is generally 
hot and dry, and all the parts sensitive. If we place one hand above 
the pelvis while the fingers of the other are in the vagina, we will 
have a consciousness of a tumor between the fingers of the two hands. 

It is not always the case that any tumidity can be felt above the 
superior strait, but generally there is tumefaction in one iliac region 
or sometimes in both. The tumefaction may extend much above 
these regions, high up into the abdominal cavity, though not often. 
If the tumefaction is considerable, the uterus is firmly fixed in its 
place, but when less, this is not the case. In childbed patients we 
may distinguish cellulitis from peritonitis by digital examination per 
vagi nam. There is not the hard tumefaction in the pelvis in the 
last as in the first. Tenderness and general distension of the abdo- 
men are greater in peritonitis ; the pulse is more rapid and is pecu- 
liar. These may and probably are often combined in puerperal 
fever, when the diagnosis is of less importance than when they are 
separate affections. The general peritoneal inflammation supervenes 
after delivery much earlier — generally on the second day — than any 
of the localized inflammations do. Cellulitis is more likely to attack 
the patient when or after she begins to make exertion, or is exposed 
to cold several days, six to ten, and even more after delivery. (See 
Pelvic peritonitis.) 

From acute metritis in the puerperal or non-puerperal state, it may 
be distinguished by examination with the finger. There is not much 
difference in the mode of attack and history between acute metritis 
and perimetritis; but by a careful survey of the pelvic organs, we 
may separate the inflamed from the sound parts. In metritis the 
uterus is generally and symmetrically enlarged, and extends lower 
down in the pelvis, and if touched at any point is tender ; in cellulitis 
this organ is not generally enlarged, and if touched anywhere in such 
manner as not to press it against or move it on the side where the 
inflammation exists, is not the subject of painful impressions. The 
tenderness in cellulitis is generally to one side of the uterus, close to 
the walls of the pelvis. If the inflammation is in the bladder, we 
may easily ascertain this fact, by pressing this organ between the 

23 



354 PERIMETRITIS. 

fingers In the vagina and those above the symphysis pubis. From 
metatithmenia It is distinguishable by the tenderness and firmness of 
the tumor, the febrile symptoms, and the history of the two condi- 
tions; cellulitis being previously inflammatory, while metatithmenia, 
when inflammatory at all, becomes so some time after the commence- 
ment of the symptoms. The bloody tumor may be handled without 
much pain, Is soft and yielding, and commences at the time of menstru- 
ating with sharp pain likened often to severe colic, without chill and 
fever at the beginning ; sometimes with collapse more or less intense. 
Carcinoma filling up the lateral parts of the pelvis, Is sometimes 
mistaken for cellulitis, but more often the latter is mistaken for the 
former. Carcinoma Is insidious in its inclpiency. It has made great 
advance before symptoms indicate its existence, while cellulitis is 
heralded by inflammatory symptoms from the start. The hardness 
of carcinoma is greater, the tumidity more irregular and devoid of 
tenderness ; it is not hot as in inflammation. The discharge from 
carcinoma when it occurs is cadaverous in odor, thin and ichorous in 
character. In cellulitis the discharge is pus, and if it smells at all, 
the odor Is faintly fecal. I have noticed this last feature in several 
instances of perimetritis, when the evacuation of the pus was free and 
copious through the vagina. 

The diagnosis from chronic metritis is not always easy. AYhen 
cellulitis is chronic, it causes many of the symptoms which we ob- 
serve to be present in chronic metritis. It will require a careful 
consideration of the symptoms and history of the case, with physical 
examination. 

Chronic cellulitis ordinarily results from an acute attack, that was 
accompanied with a discharge of pus more or less copious, and par- 
oxysms of less intensity have succeeded, growing more mild, until the 
symptoms become obscure. Paroxysmal discharge of pus is a com- 
mon symptom of chronic cellulitis. Upon a thorough and cafeful 
examination of the pelvic cavity, we may find some small spot, not 
in contact with' the uterus, but by the side of it ordinarily, that is 
hard and tender to the touch. In chronic metritis there is not always 
tenderness. 

Prognosis. 

This is generally favorable. There is probably more danger in 
attacks during the puerperal condition, or after miscarriage, than in 
unimpregnated patients, although the very large majority of these 
cases terminate favorably. Of course I leave out of this considera- 
tion such instances as are attended by general peritonitis of simulta- 



LOCAL PERITONITIS. 355 

neous origin, and constitute only a part of the whole puerperal fever. 
I do not think there is much diiference in the fatality of uncompli- 
cated cases occurring under these diverse circumstances. When cellu- 
litis proves fatal, it is generally in one of three ways: 1st. By ex- 
haustion, caused by excessive and long-continued febrile excitement, 
symptomatic of extensive inflammation. 2d. The exhausting effects 
of hectic fever, diarrhoea, diaphoresis, and want of nourishment. 3d. 
Severe complications, arising during the progress, as peritonitis, by 
extension of inflammation; or the more rapidly fatal form of peri- 
tonitis, caused by effusion of pus in its cavity. I have seen three 
fatal cases. Two of them resulted from rupture of the abscess, and 
discharge of the pus into the peritoneal cavity. One of these was 
puerperal, and death occurred ten weeks after confinement; the other 
non-puerperal, and ended in eight weeks from the attack. The one 
which proved fatal from exhausting hectic, without evacuation of the 
pus, terminated in sixty days from the commencement. 

A great many cases terminate in the chronic form. The cause of 
this sort of termination is often incomplete evacuation of the pus, 
and, as a consequence, imperfect obliteration of the cavity of the 
abscess. The pus accumulates from time to time, and fresh erup- 
tions, attended with a greater or less exacerbation of the symptoms, 
every few weeks or months, occur as this result. Or the external 
opening, wherever it may be, does not close, and there is a constant 
discharge of greater or less quantity, keeping up a kind of fistulous 
canal, leading generally some distance to the main seat of the diffi- 
culty. Or in still another sort of cases, the pus seems to be entirely 
evacuated, and the cavity obliterated, and there is nothing left but a 
small point of indurated tissue, which is the nucleus of inflammatory 
action under certain circumstances, as pregnancy, unusual excitement 
of the sexual organs, from other reasons, etc. 

Local Peritonitis. 

Post-mortem examinations, as shown especially by Goupel, demon- 
strate the fact that we may have peritonitis confined to the pelvis and 
its vicinity. Observing practitioners of long experience must have 
met with instances which, without any great difficulty, could be classed 
under this head, and I have no doubt of the practicability of gener- 
ally distinguishing them from those of cellulitis, w^ith which they are 
most likely to be confounded. 

Pelvic peritonitis is seldom primary and simple. More frequently 
it is primary, and leads to cellulitis as a complication; and in other 



356 PERIMETRITIS. 

cases it is secondary, and a consequence of pre-existing cellulitis, 
and therefore complicated with it. 

Post-mortem examinations are not always conclusive as indicating 
a condition which had existed during the entire course of the disease; 
for while in the more acute stages there may have been coexisting 
inflammation of the peritoneum and cellular tissue, the inflammatory 
action in the cellular tissue may have subsided, and the peritonitis 
alone remain to be discovered at the autopsy, and vice versa. 

This would mislead the pathologist who depended upon the post- 
mortem appearances entirely. 

Whcvi the peritoneum is primarily attacked, and the inflammation 
is confined to this membrane, it becomes injected with blood, dry, 
and rough, and in the motion to which the viscera are subjected 
during respiration, etc., the surfaces rub together and cause sharp 
stabbing pain. Upon the subsidence of this stage of the inflamma- 
tion, an effusion of serum, rich in fibrin, takes place, which gravitates 
to the most dependent part, and usually accumulates in the cul-de- 
sac behind the uterus, but does not displace the organ to any marked 
degree. The effused fluid soon coagulates, and the liquid portion of 
the serum is removed by absorption, and there is a solid mass of 
fibrin left in the retrouterine pouch. 

If the uterus happens to be retroverted at the time of the coagu- 
lation, it is fixed in that position until absorption liberates it, or 
during the life of the patient. 

The movements of the pelvic organs — and by the way these or- 
gans are always in motion, in unison with the respiratory movements, 
and as an effect of the movements of the body — sometimes modify 
the form of the coagulura, drawing it out into bands, which stretch 
from one surface to the other. 

After this serous efl^usion, the inflammation may subside and leave 
the patient comfortable, but the subject of a fixed uterus. In some 
cases, however, the absorption is rapid, and the organ is left entirely 
free in a short time. 

Should the inflammation be more intense, the epithelium of the 
membrane is loosened and falls ofl^, leaving a pyogenic surface, from 
which pus is produced in greater or less quantities when there is a 
sero-purulent effusion confined in an irregular fibrinous capsule. 

If the pus is considerable in quantity, an abscess is the result, 
which finds its way out in a manner similar to the evacuation of pus 
as a result of cellulitis. 

In the non-puerperal moderate cases of local peritonitis the serous 



LOCAL PERITONITIS. 357 

and purulent accumulatlous are confined to the pelvic cavity, but in 
the puerperal or the more intense forms of non-puerperal inflamma- 
tions, these accumulations reacli higher than the brim, and are often 
found in indurated patches in both iliac regions or over the hypo- 
gastrium. When these accumulations are round, or shaped like 
tumors, they may be mistaken for ovarian or uterine neoplasms. 

The Fallopian tubes are sometimes constricted by these fibrinous 
bands, and a portion of their cavity isolated, in which liquid accumu- 
lations collect, and give rise to Fallopian tumors, — hydrosalpinx. 

Bennett and Goupel in some instances found the ovaries involved 
in the inflammation, and either destroyed by suppuration or left in a 
state of chronic inflammation. 

Causes. 

The puerperal condition at term, or after abortion, is a very fre- 
quent, if not the most frequent, cause of local peritonitis. 

The action of cold upon the woman, when the pelvic organs are 
in a state of intense congestion, just prior or at the time of menstrua- 
tion, is also a prolific cause. 

Gonorrhoeal inflammation, by making its way through the cavity 
of the uterus and along the Fallopian tubes out upon the peritoneum, 
is, by common consent, taken to be another one of the causes; but 
inflammation may, by contiguity, also extend from the uterus to the 
peritoneal membrane. This is the case, doubtless, in the puerperal 
condition, after the violence done to the uterus by severe labor or 
abortion, and in non-puerperal cases where strong applications have 
been made to it, operations, etc. 

Direct violence to the retrouterine portion of the peritoneum is 
often done by the injudicious introduction of foreign substances by 
the patient herself, excessive coition, and by rude and ill-directed 
attempts to replace the uterus by instruments. 

Symptoms. 

Pain in the pelvis and lower abdomen is one of the most common 
and distressing symptoms, and this pain is generally characteristic. 
It is sharp, stabbing, and paroxysmal, or exacerbating. The sharp, 
stabbing, exacerbating pain is accounted for, as before said, by the 
friction of the two surfaces of the peritoneum, rendered dry and rough 
by the inflammation. In cause and character the pain resembles that 
of the early stages of pleuritis. 

While pain is one of the most constant symptoms, cases do occur 



358 PERIMETRITIS. 

in which there is very little pain, probably because early effusion, or 
some other condition, prevents the friction. Another consideration, 
which will enable us to account for the absence of pain, is the great 
difference in the susceptibility of different persons. However we 
may explain it, we know from observation that pain is sometimes 
alaiost entirely absent, and then the disease may be mistaken for 
some other affection. 

In the commencement there is a sharp febrile reaction, with its 
attendant phenomena, as quick pulse, headache, delirium, nervous 
excitement, and derangement of the secretory functions, etc. 

The intensity of the excitement will depend very greatly upon the 
suddenness of the attack and extent of the tissue affected by the in- 
flammation ; greater when sudden and extensive, and less when the 
progress of the inflammation in the first stage is slow and the parts 
involved are small in extent. The febrile reaction is usually high at 
first, and very much moderated as the effusion occurs. 

The character of both pain and febrile reaction are greatly modi- 
fied by the conditions which give rise to suppuration. As suppura- 
tion is established the sharp pain gives Avay to a sense of tension, 
weight, and heat, while the febrile movement becomes more remittent 
or paroxysmal. Debility, copious perspiration, and frequent chills 
make up the items indicative of suppuration. 

These symptoms are partially or completely relieved by opening 
the pyogenic cavity and permitting the pus to be discharged. The 
points where the pus flows, as in cellulitis, are the upper part of the 
vagina, rectum, the bladder, inguinal or femoral canal, some place in 
the abdominal wall, the gluteal region, or one of the greater lips of 
the vaginal orifice, and rarely the peritoneal cavit}^ 

If suppuration does not occur, and the case terminates in con- 
valescence without it, the symptoms gradually subside. 

Upon examining the lower abdominal region we will generally 
find tenderness upon pressure, and often more or less tumefaction, 
with or without tympanitis. The uterus, if displaced, is pressed for- 
ward, but it often occupies its normal position. In the first stage 
there is generally not much tumefaction in the pelvis felt through the 
vagina, but great tenderness behind and by the sides of the uterus. 
When the fingers are pressed well upward in the stage of effusion 
there is tumefaction behind the uterus, and sometimes in the iliac and 
hypogastric regions. 

Dlagyiosis. 

AYhen free from complications, — which, I must say, judging from 
my own observations, I believe to be less frequent than the con- 



LOCAL PERITONITIS. 359 

verse, — I do not see why there should be any great difficulty in dif- 
ferentiating local peritonitis. The affection with which it is more 
likely to be confounded than any other is cellulitis. The pain in the 
first stage of cellulitis is more steady ; is dull or aching, instead of 
stabbing or lancinating; and the tenderness, although considerable, 
is not so great as in pelvic peritonitis. In the second stage the pain 
in the two affections does not differ much, if at all. The tumefaction 
is not in the same locality; in cellulitis it is by the side or in front of 
the uterus, while in local peritonitis it is behind that organ. 

If the peritonitis extends above the pelvis, which it often does, it 
may be in one or both iliac cavities, or extend across the lower part 
of the abdomen. AVhen the effusion in peritonitis is above the pelvis 
in the centre percussion will elicit marked resonance, because the 
intestines are contained in the mass, and this resonance will enable 
us to distinguish it from a tumor. 

The history, symptoms, and physical signs enable us to decide 
between local peritonitis and retrouterine hsematocele. In peritonitis 
the history is one of inflammation, well marked in the beginning and 
throughout its whole progress, while that of hseraatocele does not 
indicate inflammation in the beo;innino; of the attack, and seldom in 
any of its later stages. In local peritonitis metrorrhagia is not a 
symptom ; in hematocele it is. Tenderness is a permanent feature 
in peritonitis, while it is very slight if it is present in hfeiiiatocele. 
This remark applies when pressure is made above the symphysis or 
in the vagina. The pelvic tumors in both disorders is ordinarily 
retrouterine, and not dissimilar in shape; but in the earlier periods 
the hsematocele is uniformly soft, while the inflammatory effusion is 
harder. The h^ematocele displaces the uterus more than the inflam- 
matory product. The tumors caused by both may and often do 
extend above the pelvic brim. The bloody tumor is generally central, 
and forms a somewhat level line across the lower abdomen, while the 
inflammatory tumor is usually irregular and hard, and is often con- 
fined to one iliac region. 

In retrouterine pregnancy the absence of acute inflammatory symp- 
toms, unless in exceptional cases, and the presence of the evidences 
of pregnancy, are strong differentiating circumstances, and will gen- 
erally lead to definite conclusions. In extrauterine pregnancy we can 
watch the case for a sufficient length of time, and the growth of the 
tumor will do much to solve the difficulty. 

The pelvic tumors formed by cancer differ from those of local peri- 
tonitis in the facts that they have no infl.amraatory history, in their 



360 PERIMETKITIS. 

great hardness, and irregularity of growth. Fibrous tumors have no 
inflammatory history, are more or less movable, more dense and 
regular in outline. The fibrous tumor is generally accompanied by 
metrorrhagia, while the inflammation is not often attended by that 
symptom. 

Prognosis. 

When peritonitis is confined to the pelvis and its vicinity it is 
rarely tatal. One of the dangers connected with it is the probability 
of its extension to the whole or greater part of the abdominal peri- 
toneum. This is much more likely to occur in puerperal cases. The 
fatal termination is sometimes the result of exhaustion induced by 
protracted suppuration and febrile excitement. 

Acute pelvic peritonitis has a strong tendency to become chronic 
by the continuance of the inflammation in a subdued form. In this 
condition, by exposure, overexertion, sexual excitement, or injudi- 
cious treatment, it may become intensified to an acute degree. When 
pelvic peritonitis has resulted in collections of pus, in portions where 
the evacuation of the fluid is imperfect, the inflammation may be pro- 
tracted to an indefinite time. Fortunately, however, in the great 
majority of cases it passes into convalescence, which is usually slow, 
but complete. 

Before giving the treatment of local peritonitis I must again say 
that this disease is so frequently complicated by cellulitis tliat its 
occurrence in the simple form is not common. I believe, also, that 
simple cellulitis is as rare as uncomplicated local peritonitis. But it 
is very often the case that the cellulitis is comparatively intense, while 
the peritonitis is not severe, when the symptoms and physical signs 
are those of cellulitis: and again the peritonitis may assume a grave 
form, while the cellulitis exists in a very moderate degree, when the 
symptoms of peritonitis will predominate. The contiguity of the 
tissue implicated in these two affections, and the identity of vascular 
and nervous supply, are facts that hardly admit of any other conclu- 
sion than that inflammation does not generally invade either of them 
and leave the other unaffected. 

Treatment oj Perimetritis. 

From what I have seen and had to do with these affections, I am 
led to prescribe in a general way the same treatment for both of them. 

In the early days of an attack of peritonitis the object of treatment 
should be to abort the inflammation, and, when this is impracticable, 



TREATMENT OF PERIMETRITIS. 361 

to limit its extent. We can seldom accomplish the first of these 
objects unless we see the patient and recognize the nature of the attack 
in the very l)eginning. It is not possible to declare just how many 
hours or days must elapse when we are no longer justified in trying 
to arrest the disease, for this will greatly depend upon the intensity, 
but we may always find something in the conditions to guide us. 
Before any considerable amount of effusion and tumefaction has taken 
j^lace we may hope to check the progress of the inflammation, even 
if this is two or three days after the commencement, or, when great 
swelling has occurred, we may still expect to limit its extent. The 
symptoms indicating the measures necessary to interrupt the inflam- 
mation are great pain, accompanied by tumefaction. These call for 
as energetic antiphlogistic treatment as the strength of the patient, 
will bear. If she is robust, from twelve to twenty leeches on the 
hypogastrium should be applied at once, and after they hav^e fallen off 
the haemorrhage nmst be encouraged by poultices or fomentations 
until, if possible, the hardness of the pulse is affected. At the same 
time a large dose of opium, or some of its preparations, should be 
administered, and repeated in such quantities as to keep the pain in 
complete subjection, and not merely given from time to time when 
the pain returns. 

If the patient is not robust we cannot resort to bloodletting, but 
we must always administer the opium in this way. As secondary 
measures the arterial sedatives may follow the depletion, when that 
is deemed advisable, or be our main reliance if we do not consider it 
best to deplete. Veratrum viride has gained such a reputation that 
it would naturally suggest itself as the most efficient of these. It 
may be given in doses sufficient to control the circulation, and keep it 
under control for the first five or six days of severe attacks. Poul- 
tices or fomentations to the hypogastric region should be one of the 
features of the treatment for the whole of the more active stao;es of 
the disease. They will often give marked relief. Large injections 
of very warm water, the patient lying on her back, should also be 
employed. An apparatus that will permit the water to run off with- 
out wetting the clothing will be indispensable to the proper manage- 
ment of the injections. This kind of treatment will sometimes check 
the force of the attack in a very short time by arresting or limiting 
the extent of the inflammation, and thus sav^e the patient from the 
protracted suffering which neglect of energetic treatment is sure to 
entail. 

After the effusion has taken place, and before the period of sup- 



362 PERIMETRITIS. 

pnration has arrived, alteratives, such as mercury and iodide of 
potassium, are very important remedies. The former may be given in 
small and frequently repeated doses, until the slightest possible indi- 
cation of its general effects are noticed, when it should be displaced 
by the iodide. This is the period when decided saline laxatives are 
useful and advisable. 

When the symptoms indicate the commencement of suppuration 
we can no longer continue all of the foregoing treatment. 

The opiates may now be given when the pain requires it. The 
regimen and medication should be changed to quinine in liberal doses, 
two to four grains or more, as often as necessary, to keep up its in- 
fluence, and supporting food in as large quantities and such quality 
as the stomach and rectum will bear. 

Unfortunately we are often called upon to treat patients who have 
already passed the time when any other than the supporting and 
anodyne treatment would be entirely out of consideration, because 
many of these patients have been too greatly reduced by preceding 
influences to permit of any other than anodyne and supporting treat- 
ment from the beo-innins^. These are the unfortunates who lino-er for 
weeks, and sometimes for months, in spite of anything we can do for 
them. 

During the progress of perimetritis there is a time when counter- 
irritation will be of great service. After the more acute symptoms 
have subsided, and effusion is evident, a blister applied over the iliac 
region, where the pain is greatest, or over the hypogastrium, if that 
is the location of the most pain, will be required. 

The blister applied at this time will often relieve the deepseated 
pain, prevent the effusion from becoming purulent, and excite the 
absorbents to remove it. 

Later in the disease tincture of iodine will go far toward accom- 
plishing the same objects. 

A question arises at the suppurative stage of the affection which 
must be decided after a careful survey of the whole case, viz., should 
we evacuate the pus, or should this process be wholly left to nature? 
As one of the disastrous terminations is a rupture in the peritoneal 
cavity, as nature often selects very circuitous and unsatisfactory via- 
ducts, as the rectum, bladder, etc., and as a consequence of this last 
circumstance the recovery is very much protracted, I think we should, 
when practicable, furnish the pus an outlet of our own choosing, and 
as early as can conveniently be done. Soon as evidences of suppu- 
ration begin to be manifested through the general symptoms, we 



TREATMENT OF PERIMETRITIS. 363 

should make a? thorough au examination as we can to ascertain where 
the collection has occurred. If we can discover the pus, we evacuate 
without apprehension of damage to any of the organs. If our first 
examination fails to satisfy us, it should be repeated as often as ev^ery 
twenty-four hours until the discovery is made. When this is done, 
we institute one or two precautionary measures, which will almost 
preclude the possibility of doing harm by an intelligent penetration. 
The first is to completely evacuate the contents of the bladder and 
rectum by the catheter and an injection. Vie ought to be sure that 
the rectum is empty of fluid and gas. I knew fluid in the rectum to 
so far deceive a practitioner as to cause him to make preparation for 
its puncture. We ought to pass the catheter into the bladder and 
rectum after we sit down to operate. The next precautionary measure 
is to introduce the exploring trocar into the tumor, and after the pus 
has made its appearance, open the cavity by the side of the retained 
canula. In this way I think there is great safety in the operation. 
The patient may be prepared for the puncture by being placed ou 
the left side before a good light, as if for operation for vesico- vaginal 
fistula, and anaesthetized. The part may be exposed by Sims's specu- 
lum. The instrument most convenient for making the incision is a 
tenotomy knife. The opening should be free and direct, so as to 
permit of a ready discharge. The opening should not be allowed to 
close. This may be prevented by keeping a tent in the wound until 
the pus ceases to be discharged. The objects of thus opening the 
cavity are to secure an external and safe outlet and its ready evacua- 
tion, and thereby attain a speedy cure and safety against peritoneal 
inflammation. When the chronic form consists in frequent repetitions 
of the inflammation, on account, perhaps, of its imperfect subsidence, 
much may be done by persistent counter-irritation, and among the 
best kind is a seton in the groin kept running for months. An issue 
will have equal good effect. This permanent form of counter-irri- 
tation is better, I think, than blistering or pustulation. When the 
opening into the intestine or bladder becomes fistulous, as it some- 
times does, and the discharge continues for months and even years 
if there is no vaginal opening, and the discharge is into the bowel or 
bladder, we should seek for a point in the tumor where it may be 
punctured, and the opening made free and direct through the vagina. 
If no such point can be found, we cannot, with propriety, interfere 
surgically. The openings are, however, often located so that we may 
easily reach them, as through the lower part of the abdominal walls, 
the labia, the gluteal region, the perina^um, or vagina. If the orifice 



364 PERIMETRITIS. 

is accessible, we may generally succeed in obliterating the suppurating 
cavity and fistulous canal. Preparatory to making an effort to do 
so, we should try to ascertain the tortuosities of the fistulous duct 
and the depth of the pus-cavity. In some instances the canal is so 
crooked that the straight probe will pass but a very short distance, 
and it becomes necessary to send it in various ways; and sometimes 
an elastic or elm bougie will suit better for a probe than the ordinary 
metallic one. Professor Simpson recommends leaving a wire in the 
track of the fistula until adhesive inflammation is excited. I have 
not tried this means, for I have been so well pleased with injections 
of carbolizecl water that I have used them almost exclusively. I 
inject through a small-sized catheter. The smallest-sized elastic 
catheter, pushed to the bottom of the cavity, will convey the fluid in 
its concentrated strength to the bottom, and thus produce the effect 
at that point. We ought, after introducing the catheter, to inject the 
cavity with tepid soapsuds, so as completely to cleanse the internal 
parts of pus, and then immediately throw up the solution. 

Sometimes the first injection does away with the production of pus 
and produces adhesive inflammation. In order effectually to inaugu- 
rate the treatment, it sometimes, indeed generally, becomes necessary 
to slit up the orifice of the fistula somewhat, as it is usually smaller 
than any other part of the duct. 



CHAPTER XXIIL 

CHROXIC PEEIA[ETEITIS. 

Chronic perimetritis is a common form of disease. It is the 
cause of much sulferino; aDil is often misunderstood. 



c 



Causes. 

By far the greater number of cases can be traced to the acute form, 
but there is no doubt that many others have an entirely different 
origin. 

Most practitioners of extensive observation must have seen many 
cases of chronic perimetritis, in the history of which no evidence 
could be found that the patient had ever had an acute attack. 

We know that the acute form is often the result of an extension 
of inflammation from the uterus and vagina to the broad ligament 
and peritoneum, and I think I have seen instances where inflamma- 
tion of a moderate grade had been propagated from the uterus and 
remained thus associated for an indefinite length of time. 

This I think is the right way to account for those cases so fre- 
quently found complicating chronic uterine diseases, and in which the 
symptoms of perimetritis are completely masked by those attending 
the more prominent affection. 

It is indeed very seldom either in the acute or chronic form that it 
is not accompanied by inflammation of the uterus, and it is ecjually 
rare that the disease is not propagated from the uterus or vagina. 

In very few cases it is reasonable to suppose that the inflamma- 
tion may originate in the ovaries. 

I do not hesitate to assert, however, that I have not seen any cases 
of acute or chronic perimetritis, — where their history could be clearly 
traced, — that were not secondary in their origin and transmitted from 
the uterus. 

Vat^ieties. 

Chronic perimetritis presents quite a variety of appearances ; one 
form traceable directly to the acute attack is chronic abscess. 

After the process of suppuration has led to a discharge of pus, 
and the acute symptoms have subsided, the patient still suffers from 



366 CHRONIC PERTMETRITIS. 

tenderness, pain, and long-continued suppuration. The pyogenic 
cavitv is perpetuated by the imperfect discharge of pus. AYhile the 
pus is being constantly discharged, the sac whence it comes is not 
entirely emptied, and there is enough pus generated to keep up a 
perpetual drain. The manner in which the original opening was 
affected is almost always the cause of this imperfect evacuation of the 
abscess. The canal or conduit leading from the cavity is tortuous, 
and penetrates the muscular fibres of the rectum or bladder diagonally, 
so as to form a valvular opening. The pus after having travelled 
along between the different muscular layers of the walls of one of 
these organs, makes an opening that is closed with every contraction 
and opened with each relaxation of the fibres. Still another unfor- 
tunate method of perforating the intestinal tube or bladder is when 
the level of the sac is below the opening. In all of these ways the 
complete evacuation may be prevented and the discharge protracted 
for years. We meet with another form of perimetritis in which the 
abscess seems to have been cured after complete evacuation. The 
subsidence of the symptoms is so complete as to leave the patient in 
the enjoyment of fair health. After a time, of greater or less dura- 
tion, sometimes a few weeks only, at others several months, tlie symp- 
toms recur in a less severe degree than in the acute form, and after a 
duration of several days or weeks a discharge of pus is again suc- 
ceeded by relief. 

These attacks are repeated an indefinite number of times, and if 
the patient recovers it is after a number of months or years. 

The suffering is sometimes very great and followed by large dis- 
charges. More frequently, however, the pain is not so excruciating 
and the discharge of pus is small. 

Again, other cases are met with in which the progress of the in- 
flammation from the beginning is very slow, and not attended with 
very severe pain, but continues until quite a large amount of pus is 
formed, which remains in the sac, with very little tendency to ulcerate 
through the tissue. Whether the pus in some of these cases would 
ever be discharged by spontaneous processes is a matter of great un- 
certainty. I have seen cases where from the history I felt assured 
that this indolent abscess had existed for years. 

I saw a case in this city with Dr. T. D. Fitch, that he informed 
me had been in the condition it was when I saw it for three years. 
That he had seen it, discovered pus, and advised its evacuation, as 
long as that, before I was called. I have seen others equally pro- 
tracted in my own practice and in consultation. 



( 



VARIETIES. 367 

Some cases are met with, the history of which includes a Dumber 
of recurring acute or subacute non-suppurating attacks, weeks or 
months apart, that finally culminate in suppuration. Patients suf- 
fering from this form have an attack of fever, with pain in the 
pelvis, pains running down the limbs, tenderness, and perhaps very 
slight tumefaction of the hypogastric region. This pas-es for '* in- 
flammation of the bowels.^' The patient more or less completely 
recovers from the attack, and after a time is again prostrated with 
similar but less pronounced symptoms, these run a course of four or 
six weeks and the patient again recovers. This time the fever may 
be called typhoid or bilious fever ; in a subsequent attack suppura- 
tion reveals the true character of the disease. The explanation of all 
these symptoms is that the patient had several attacks of moderate 
perimetritis, that for want of proper physical examination were mis- 
understood and called by different names. 

All gynaecologists engaged in extensive practice frequently meet 
with such cases. 

But all cases, nor even a large proportion of them, do not end in 
suppuration. The exudate in these cases does not break down, but 
continues hard, and is formed in masses of greater or less size in the 
broad ligament, attached to the side of the uterus, or between the 
uterus and bladder. Or where the disease is in the peritoneum the 
exudation may be above the brim of the pelvis in the iliac region. 
These deposits of fibrin are often mistaken for tumors. Xot uufre- 
quently a large part of one side of the pelvis is filled with a hard 
immovable mass of plastic effusion, and the uterus misplaced and 
fixed in its malposition. In other instances the accumulation is 
small and does not affect the position or mobility of that organ. 

Instead of the localized effusions here described, sometimes there 
is a diffuse moderate infiltration of fibrin in the cellular tissue that 
causes thickening of the ligament. The parts are less elastic than 
usual, the uterus less movable yet not fixed. 

This condition is the one most frequently present when the uterus 
is said to be " bound down," so that it cannot be reposited and re- 
tained in position without causing great suffering or awakening acute 
inflammation. 

There is also a very moderate degree of chronic inflammation — 
hypersemia with sensitiveness — which invades and remains in the peri- 
metric tissue without causino^ effusion or anv considerable deo^ree of 
tumefaction. 

Whether this degree or form of disease is one introductory or pre- 



368 CEROyiC PERIMETRITIS. 

paratorr to the more grave acute grade, or one that may last indefi- 
nitely, without any great yariation in intensity, is not certain. It is 
probably the condition to which the term — so frequently used — 
*Matent inflammation '^ is applied, because under certain favoring 
circumstances the vascular and nervous action is developed into the 
acute form. 

I have no doubt that this low degree of iniiammation may exist 
a loner time, and perhaps indefinitely, in the absence of causes excit- 
ing it to a higher grade of action. 

Symptoms and Diagnosis. 

Generally the symptoms of chronic perimetritis are not distinctive, 
and arrange themselves under the general head of " Uterine Symp- 
toms." In those cases in which pus is formed the symptoms l)ecome 
more marked, and we may not be at a loss to understand them ; but 
even in some of these the symptoms are not decisive. We must, for 
the most part, therefore, depend upon physical examination. The 
history of those cases of frequently recurring paroxysms of pelvic 
inflammation, which for many months, or even years, precede sup- 
puration, will often indicate pretty clearly the character of the dis- 
ease with which we have to deal. Yet, without an examination of 
the pelvic organs, even these cannot be diagnosed until they have 
about i-un their course. 

There is geoerallv one element which, to one whose attention is 
attracted in that direction, will be found to be almost always present, 
viz., fever in a more or less marked d^ree. In all but the indolent 
abscess, and the slighter degree of its form, in which there is no exu- 
dation, this symptom will pretty uniformly present itself. 

Physical examination will uniformly develop sensitiveness. It 
will often happen that, during the examination^ the tenderness will 
be so slight as not to elicit complaint from the patient ; but. after the 
manipulation is ended, there will be left aching and a sense of ten- 
derness. Sometimes the reaction will be quite severe and last for 
hours, or even awaken an acute attacl:. This subsequent tenderness, 
however slight, is a symptom of much significance, and should teach 
caution in future examinations. 

Another important sign (yet not so important as the last) is certain 
positions of the uterus. When the cervix is drawn strongly to one 
side, and especially if it is fixed in tliat position, it indicates an ir- 
regularity in the length of the broad ligament. The ligament of the 
side toward which the traction is noticed is shortened, and, while not 



TREATMENT. 369 

invariably so, the shortening is frequently owing to previous or 
present inflammation in the connective tissue of the ligament. If 
associated with tenderness this condition ought to complete the diag- 
nosis. As has been pointed out by Dr. Emraett, this condition is 
often present in cases of laceration of the cervix. 

Bimanual examination of the sides of the pelvis will generally 
enable us to detect even a small amount of fibrinous deposits. They 
may generally be diagnosed from tumors by their tenderness, fixed- 
ness, and locality. In most cases they will be fixed to the pelvic 
walls, especially when situated, as most of them are, in the connect- 
ive tissue of the broad ligament. Sometimes, however, they are 
developed at the side of the uterus, and adhere firmly to it. In such 
cases they move with the uterus, and cannot be made to move upon 
that organ. These are more likely to be mistaken for subserous 
fibrous tumors. The history will do something toward clearing up 
the diagnosis. There will always be a history of inflammation. The 
menses are not so likely to be profuse as in the case of fibrous tumors. 
Each manipulation will be attended or succeeded by tenderness. 
When the deposit is extensive the position of the uterus is generally 
affected by it also. The indurated patches at the brim of the pelvis, 
left by local peritonitis, are sometimes mistaken for tumors. We 
should give due weight to the history of inflammation, with which 
these are connected, and the tenderness that is developed by pressure, 
and other manipulations. When examining them we will generally 
find them flat instead of globular, and not movable. But the most 
remarkable, and, I think, pathognomonic sign, is resonance under 
percussion. However extensive these indurated masses may be, per- 
cussion will elicit intestinal resonance over the whole space occupied 
by them. The resonance is due to the fact that the effused fibrin 
surrounds, instead of displaces, the intestine, and in coagulating in- 
cludes that tube in the indurated mass. These signs are all different 
from those evinced by an examination of a tumor. The signs of the 
indolent abscess of the broad ligament are an immovable tumor, 
which is elastic or fluctuating, and the test is aspiration. 

Treatment. 

The treatment of these several diverse conditions must necessarily 
vary. The form in which sensitiveness and hypersemia are not 
attended w4th effusion will require great circumspection in the treat- 
ment. 

One is continually tempted by local inconvenience to depend too 

24 



370 CHRONIC PERIMETRITIS. 

much upon local treatment, whereas I think it is benefited less by 
local measures than any other form of the disease. It is, in fact, more 
frequently connected with, if not dependent upon, some dyscrasia (or 
dysthetica) than upon local conditions, and hence must be treated 
largely by general measures. One of the most efficacious of these 
measures is a judicious change of climate and habits. The object in 
making a change of climate and habits should be to revolutionize the 
circumstances of the patient. It is astonishing how these patients, 
who cannot stand upon their feet, on account of the great sensitive- 
ness of the pelvic organs, will improve on a long journey, which, 
from the symptoms, would seem impracticable. A trip to, and resi- 
dence in, California has done more to cure some of these patients than 
could have been done by medicine alone. But much good can be 
done by medicines, such as will improve the condition of the system. 
The bowels should be the subject of special care. They will more 
frequently than otherwise be constipated, and their secretions de- 
praved in quality, as well as scarce in quantity. The mercurials and 
bitter tonics, if perseveringly administered, will often correct the con- 
stipation, improve digestion, and act favorably on the depraved state 
of the general system. 

The sixteenth of a grain of the bichloride of mercury, with a full 
dose of the compound tincture of cinchona, or the tincture of columbo, 
three times a day, makes an excellent mixture for such cases. The 
diet should be full in quantity and nourishing in quality. Exposure 
to the fresh air and sunshine is also indispensable to restoration. The 
exercise should not be too much restricted, because confinement 
always aggravates the general condition, and moderate exercise is not 
harmful to the local trouble. The special treatment should consist 
in large injections of tepid water, and extensive but very moderate 
counter-irritation. 

The counter-irritant I rely upon most is the tincture of iodine, 
diluted with an equal quantity of alcohol. This liniment should be 
applied over the whole lower part of the abdomen, back, and hips. 
I believe, however, that the local treatment can often be dispensed 
with if judicious management of the general health is persevered in 
and diligently applied. 

In the cases in which fibrinous deposits are observed, special treat- 
ment is of more importance. And the first thing that I would insist 
upon is that pessaries and stimulating applications to the uterus 
should be abjured. 

Large hot or tepid water injections and sitz-baths will be of great 



TREATMENT. 371 

service. It will sometimes be found that hot-water injections will 
cause discomfort, while tepid water will be followed by relief, and the 
effect experienced from them should guide us in our choice. 

Concentrated counter-irritants in the inguinal regions will also be 
found very beneficial. A small seton I believe to be the best form of 
counter-irritant, and when kept clean and shielded from the friction 
of the clothing it will give the patient but little inconvenience, and 
we must not forget the soothing influence of glycerin tampons. 

Diligent attention to the general health is of the greatest import- 
ance also, and very small doses of mercury, laxative diet, and expo- 
sure to pure air in a mild climate will generally suffice. In the sup- 
purative variety, which is but the advanced stage of the latter form, 
attention to the general health is of paramount importance. When 
the suppuration is intermitted with intervals of comparative comfort, 
we may generally interrupt the paroxysm by establishing and keep- 
ing up for a considerable period a discharge from the iliac or in- 
guinal region over the seat whence the discharge emanates. I know 
of no one remedy that does so much good as the seton. It should be 
larger than in the last variety, and the local irritation kept up for 
several weeks or even months. 

When the suppuration is continuous, in addition to attending to 
the general health, we should try to establish a more direct outlet. 
When the discharge is from the rectum we may sometimes pass a 
bent probe through the opening and bring its point down upon the 
roof or side of the vagina, and make it a guide to a puncture in that 
direction. When we cannot improve the direction of the outlet we 
may sometimes destroy the pyogenic character of the cavity by injec- 
tions of carbolized water through a flexible catheter, introduced and 
carried to the bottom of the cavity. 

In the case of the indolent abscess all that will generally be found 
necessary is to draw off the pus by the aspirator. In this variety the 
lining membrane (or wall) of the cavity has ceased to produce pus, 
and consequently when the sac is emptied the fluid does not reaccu- 
mulatc. I have seen several cases thus happily terminated. 



CHAPTEE XXIV. 

DISPLACEMENTS OF THE VAGINA, BLADDER, AND RECTUM. 

In every displacement of the uterus the direction of the axis and 
the calibre of different parts, or the whole of the vaginal canal, are 
changed from their normal conditions. In procidentia the vagina is 
in part or wholly inverted. In such cases, however, the changes are 
complications of the displacements of the uterus, and are described 
and treated as such. 

The more common and yet not entirely independent displacements 
of the vagina are known as cystocele and rectocele. 

Cystocele. 
Cystocele is a prolapse of the anterior wall of the vagina, being 
borne down by a prolapsed bladder, or drawing down that organ 
with it. The prolapses of the anterior vaginal wall and bladder may 
also make sufficient traction upon the uterus to cause prolapse of 
that viscus, and thus be complicated by it without the posterior wall 
of the vagina being much disturbed. Still another thing may be said 
in this connection. Sometimes the mucous membrane of the anterior 
or posterior wall of the vagina may prolapse through the vulva 
without displacing the fibrous sheath,- the bladder, or the rectum. 

Rectocele. 

When the posterior wall of the vagina protrudes externally it is 
generally attended with displacement of the anterior wall of the rec- 
tum, and sometimes the uterus is drawn down and displaced by trac- 
tion of the wall of the vagina. 

The symptoms of cystocele are dragging sensation or weight in the 
vagina, with leucorrhoea and burning pain, occasioned by the inflam- 
mation from the exposure or friction of the mucous membrane of the 
vagina, and vesical suffering. In recent cases there is simply frequent 
desire to micturate and unsatisfactory discharge of the urine. 

As the case becomes chronic the incomplete discharge_of urine leads 
to its decomposition, the precipitation of the salts contained in it, and 
the evolution of ammonia. 

The ammonia and salts irritate the raucous membrane of the blad- 
der to a greater or less degree, and in aggravated cases severe inflam- 



RECTOCELE. 373 

mation and ulceration occur, attended with discharge of mucus, blood, 
and fetid gases. 

These local results are attended by constitutional disturbances com- 
mensurate with their gravity. 

The sufferings in rectocele are usually less severe. There is 
weight, leucorrhoea, and unsatisfactory defecation. The muscular coat 
of the rectum loses its tone and permits the faeces to collect in a 
large mass in it, which intrudes into and fills up the vagina. 

When an effort is made to expel the excrement it collects in larger 
quantities and remains in this passive pouch until the patient presses 
or scoops it out with her fingers. 

Diagnosis. 

Upon examining the vagina the anterior or posterior prolapse will 
be readily discovered, and may be isolated by passing the finger into 
the vagina. If the anterior wall is prolapsed the finger wull pass 
behind the tumor, and in front of the tumor if the posterior wall is 
the portion affected. 

We may demonstrate a cystocele by introducing the catheter. The 
instrument, instead of passing backward and upward, will go down- 
ward and backward, and the point may be felt occupying the tumor. 
In rectocele, if we introduce the finger into the rectum, it may be 
turned forward toward the vagina and made to enter the tumor. If 
the prolapse consists of the mucous membrane alone, the finger or 
catheter will not pass into the tumor. 

Causes. 

Loss of substance or tone in the perinaeum is one of the most im- 
portant conditions necessary to prolapse of the vagina. There may 
be loss of substance in the anterior border of that body from rupture, 
or loss of firmness from subinvolution, lack of general muscular 
vigor, — debility, — or senile atrophy. 

In old women we not infrequently find all the genital organs in a 
state of abnormal relaxation from loss of fibrous tissue. 

Instead of normal atrophy, in which the parts are condensed, as 
the fibrous tissue disappears, there is no contraction, and the uterus, 
vagina, and perinaeum are reduced to their membranous structures, 
incapable of resisting force in any form. Subinvolution of the va- 
gina, bladder, and rectum, on account of the vascularity and laxity 
attendant upon that condition, permit displacements, which are fa- 
vored by the weight of these and other pelvic organs. 



374 DISPLACEMENTS OF THE VAGINA, BLADDER/aND RECTUM. 

Retention of the urine and faeces are also important factors in the 
displacements. They distend and weaken the walls of the viscera 
until they become incapable of resisting the pressure. 

Treatment. 

The same general principles govern the treatment of these two 
conditions. 

If the perinaeum is deficient^ its integrity should be restored by 
perinseorrhajDhy, and this will often be sufficient to eflPect a cure of 
either or both. 

When there is no loss of perinaeum, or the deficiency is slight, we 
may often cure cystocele by returning and retaining the prolapsed 
portion in position until the redundancy of tissue is reduced by the 
contraction and condensation which take place when the distending 
forces are removed or counteracted. 

The instrument which I have found most serviceable in cystocele 
is Zwanc's pessary. The points upon which it rests are the rami of 
the ischium, and it presents the flat surface of its expanded wings 
upward, affording an admirable lodging-place for the redundant tis- 
sue. The application of this instrument is not difficult, and when 
of the right size it very generally relieves the symptoms at once, 
especially the irritableness of the bladder. It will be necessary for 
the patient to wear the pessary for many months until the condensa- 
tion or involution is complete. Like every other pessary, this one 
should be removed and examined often enough to insure cleanliness 
and prevent damage to the vagina. 

If it causes ulceration it must be removed at once. Sometimes a 
ring, kept in position by external support, may be made to retain the 
procident wall quite securely. The practitioner should rely upon 
the pessary in most instances of this kind as far preferable to other 
surgical means, except the restoration of the perinaeum when deficient. 

When a surgical operation is required, the object to be attained by 
it is to remove a portion of the redundant mucous membrane over 
the central part and draw the edges together, and thus lessen the 
calibre of the vagina. 

To the inexperienced this operation seems a formidable one, but it 
is not so, and when attempted the difficulties will rapidly vanish. 
In the natural condition, the mucous membrane of the vagina is 
attached to the fibrous sheath by very loose connective tissue. In 
cystocele the space is much greater, hence, with a tenaculum we can 



RECTOCELE. 375 

lift the membrane freely away from the vaginal sheath and with the 
scissors remove it to any extent we desire. 

As before remarked, the protrusion in many instances is made up 
of the mucous membrane alone, w^hen the operation is easy and a 
complete success. 

When the fibrous wall of the vesico-vaginal space yields, and is 
prolapsed with the mucous membrane, the operation is much more 
likely to fail, and we will at Fast be obliged to resort to a support. 

Judging from my own observation, I should say that rectocele is 
hardly curable in any other way than by operation. The perinaeum 
is almost, if not always, deficient, which requires an operation for its 
restoration. When this is the case, the two may be cured by the 
same operation. The more protuberant part of the rectocele is at the 
perinseum, and this portion may be denuded as far as necessary and 
closed with the perinseum, or a single ligature may be made to sur- 
round the part denuded like a puckering string, and the whole may 
be closed up and drawn down upon the perinseum. 

If the perinseum does not require an operation, then a similar 
operation to that recommended in cystocele may be performed. 

Dr. Gillette, of !N"ew York, performs an operation for condensing 
the mucous membrane without removing it, by passing silk ligatures 
between the membrane and the fibrous sheath and drawing it up over 
the most protuberant portion. Silver wire sutures are generally used 
for drawing the edges of the mucous membrane together over the 
denuded part. 

The manipulation will be suggested with sufficient accuracy in 
what is said about the use of instruments in the operation for vesico- 
vaginal fistula, — perinseorrhaphy and an examination of the figures. 

The after-treatment is of great importance. The patient should 
be kept quiet in bed and have opium enough to relieve pain, and in 
cystocele the urine should be evacuated by the catheter often enough 
to prevent distension. In rectocele the rectal tube must be used to 
prevent the accumulation of gas, and the bowels moved by saline 
laxatives every other day. Salines should be used because they 
liquefy the stools. 



CHAPTEE XXY. 

DISPLACEMENTS OF THE UTEKUS. 

The womb may be displaced when not pregnant, when pregnant, 
parturient, or puerperal. 

In the unimpregnated condition the more common forms of dis- 
placement are lapse, prolapse, protrusion, retroversion, anteversion, 
retroflexion, and anteflexion. Another rare form of displacement is 
upward. This is generally caused by attachment to tumors, with the 
development of which the uterus is lifted upward. It is also dis- 
placed by effusions and tumors forward toward the pubis, and back- 
ward toward the sacrum, without change of axis. These latter changes 
in themselves are of but little importance, and will be corrected by the 
removal of the tumor or effusion, when that is practicable or neces- 
sary. 

The natural position of the uterus is not precisely the same in 
every individual. It is generally situated very near the centre of 
the pelvis, with the fundus directed a little forward of the axis of 
the brim, and is, probably, a quarter of an inch below the plane 
of the superior stmit. In the virgin, more frequently than other- 
wise, there is slight anteflexion. The lower end of the cervix is very 
little below the level of the arch of the symphysis pubis, with the os 
turned slightly forward. Very often the fundus is turned in a small 
degree to one side or the other. This description has reference to the 
cavity of the pelvis, and not to the line representing the longitudinal 
axis of the body. The variation of the position ©f the pelvis in 
relation to the axis of the body is very great, and this variation will 
carry the axis of the uterus with it. In the woman who stands erect, 
with her shoulders thrown well backward, the axis of the uterus is 
almost horizontal, and nearly at right angles with the perpendicular 
axis of the body. On the contrary, the woman who stoops or throws 
the shoulders forward causes the direction of the axis of the body and 
superior strait of the pelvis to approach the same line. 

The more nearly the longitudinal axis of the bod}^ and the axis 
of the superior strait correspond, the 'more the abdominal organs 
press into the pelvis. In addition to the permanent or fixed relation 
of the pelvis to the trunk it must be borne in mind that the move- 



) 



1 



NATURAL D-TERINE SUPPORTS. 



377 



Fig. 106. 



ments of the body are continually effecting temporary changes in 
these relations, and that some avocations keep the pelvis flexed upon 
the trunk from six to ten hours daily. 

In considering the natural position of the uterus we should not 
forget its great mobility — a provision of salutary importance — a cir- 
cumstance that serves to continually correct its position when the 
displacing influences are withdrawn. 

Xatural Uterine Supports. 

It is not a very easy matter to determine all the agencies concerned 
in retaining the uterus in its natural position. From what has been 
said the reader will infer that I consider the rela- 
tive position of the axis of the pelvis and body one 
of the agencies. At the brim of the pelvis the 
broad and the round ligaments are unmistakably 
supports to the uterus in keeping the fundus in 
proper position with reference to the pelvic circle, 
as well as to prevent its prolapse. The broad liga- 
ments are not strong, but they are elastic, and, while 
their power to prevent displacement is not very 
great, they are sufficiently elastic to replace the 
organ against moderate force. Their perpendicular 
duplicature embracing the uterus is greatly strength- 
ened by the considerable amount of connective 
tissue which they contain between their folds. This 
connective tissue not only connects the folds of the 
peritoneum, but extends from the wall of the pelvis 
to the sides of the uterus, and is thus a direct means 
of support to the organ. In the pelvic cavity the 
utero-sacral ligaments, formed by folds of the peri- 
toneum, with a large quantity of connective tissue and prolongations 
of pelvic fascia, are efficient ligaments. 

Below the uterus, the vagina, and the connective tissue binding it 
to the pelvic walls, at the side and in front, and further strengthened 
by the pelvic fascia, make decided resistance to displacing agents. 

In the chapter on the perin^eum I have already said sufficient in 
regard to its agency in supporting the uterus. All these supporting 
agencies are affected by physiological conditions which strongly modify 
their efficiency. Pregnancy, by the general hypertrophy it brings 
about in all the genital organs, completely disqualifies them as sup- 
porting agencies, and, until they are reduced to their proper firmness 




Xatural Position of 
the Bodv. 



378 



DISPLACEMENTS OF THE UTERUS. 



Fig. 107 



and length by involution, their effects in this direction are nothing. 
From recent physiological teaching we must believe that their sup- 
porting power is also reduced by the congestion and trophic changes 
accompanying menstruation. These varying efficiencies of the natural 
supports of the uterus are considerations of great importance in con- 
nection with the etiology of displacements. 

Causes of Displacements. 

In speaking of the direction of the pelvic axis I have already 
intimated that women who, from disease, debility, occupation, languor, 
or any cause, habitually stoop, and thus bring the axis of the pelvis 
nearly to correspond with that of the body, place the uterus in a posi- 
tion to be easily displaced. The pressure of the abdominal viscera 
upon its fundus, increased with the percussion of coughing, sneezing, 
and respiration, injuriously bear upon it. In 
these patients ascending stairs, walking, stand- 
ing, etc., produce an exaggeration of these 
effects. 

The position occupied by working on the 
sewing-machine, or even sewing by hand, 
ironing, washing, etc., is more mischievous 
than the work itself; and, if the same things 
were done with the body erect, they would be 
comparatively innocent. 

Increase in size, and consequent weight of 
the uterus from tumors, congestion, inflamma- 
tion, subinvolution, and elongation of the cer- 
vix are causes of displacement. When the 
size is increased in all its proportions the 
tendency is to prolapse ; if the increase of 
weight is confined to the fundus there will be 
Unnatural or Stooping Posi- an inclination to antevcrsiou or anteflexion, 

tion of the Body. • n • 

retroversion or retroflexion. 
Sometimes the thickness or increased weio:ht is in the anterior or 
posterior wall, then the inclination will be in the direction of the 
disease. I believe that pre-existing disease is the cause of displace- 
ments of the uterus in the great majority of instances, and that 
displacement is very seldom the cause of the disease usually asso- 
ciated with it. Loss of tone in the ligaments, flabbiness and soft- 
ness of the vagina, relaxation of the attachments composed of fascia 
and connective tis.sue, and the want of strength in the perinseum, 




LAPSE. 



379 



except when torn, generally depend upon coexisting disease, as sub- 
involution, general debility, senile atrophy, etc. There is no doubt, 
however, in mv mind that the uterus weio^hinor an ounce more than 
natural, especially in a person in whom the plane of the superior 
strait of the pelvis is too nearly horizontal, will in time overcome 
the resistance of all the means of support with which the uterus is 
surrounded, and determine a displacement of some kind. 

Conditions outside the uterus, as a loaded condition of the intes- 
tines, which causes them to settle down upon the pelvic organs, 
straining at stool, especially when there is impaction of the rectum, 
jolts from jumping, straining from lifting or reaching, maybe causes 
of displacement. I think it is impossible thus to displace a uterus 
otherwise in a healthy condition ; but I do believe that such acts are 
the etiological items that complete a process already begun. I have 
not attempted to enumerate all the causes of displacement of the 
uterus. It is my design, in a general way, to merely indicate the 
manner of their action. In most cases many causes co-operate to 
bring about a displacement. 

Lajyse. 

Simple falling of the womb in the direction of the axis of the 
superior strait brings it into a position in which the lower end of the 

Fig. lOS. 




Lapse or Descent of the Uterus, without change of axis, and the Displacement of the Bladder 
and Pressure upon the Rectum. 



cervix is inserted behind the apex of the perineal body, while the 
fundus is from half an inch to an inch below the ordinar)^ level, and 



380 



DISPLACEMENTS OF THE UTERUS. 



sometimes even more. In this displacement the lower wall of the 
bladder is drawn dow^n in consequence of its attachment to the 
uterus, and occasionally a reservoir for the retention of urine is thus 
produced. 

When this is the case dysuria is oue of the symptoms. When of 
long standing, pressure upon the rectum gives rise to tenesmus, de- 
velops haemorrhoids, ulceration of the mucous membrane of that 
viscus, constipation, etc. 

This form of displacement is probably generally caused by some 
form of hypersemia of the uterus instead of primary relaxation of 
the supports. 

Prolapse. 

When the perinseum is deficient, relaxed, or overcome by long- 
continued pressure, the cervix turns forward and the body of the 
organ lies in the vaginal canal, with the fundus backward upon the 



Fig. 109. 




Prolapse of the Uterus. 



level, or, rather, above the level of the cervix. In this position with 
reference to the vaginal canal and the axis of the inferior strait, the 
organ may slide forward until the cervix extends to and even through 
the vaginal orifice. With this kind and degree of displacement there 
is some change in all the pelvic and lower abdominal viscera. The 
bladder is drawn down until the direction of the urethra is changed. 
The Fallopian tubes and ovaries are moved from their natural posi- 
tions, and the rectum is generally more or less displaced forward and 
downward, while the intestines sink down into the pelvis, and by 
their weight increase the uterine displacement. 



PROTRUSION. 



;8l 



Of course the resistance of the ligaments is overcome to permit of 
such prolapse, and the vagina is more or less inverted. 



Protrusion. 

After the cervix has passed beyond the vaginal orifice, the direc- 
tion of its descent is again changed, and when the whole organ is 
expelled or dropped from the body, the longitudinal axis of the 
uterus corresponds with the perpendicular axis of the bodv. 

The utenis hangs down between the thighs. The extent and size 

Fig. 110. 




Protrusion of the Tterus. with attendant cliange in the position of the Bladder and 
Inresiinal Canal. 

of the protrusion is of course variable. Sometimes the whole of the 
uterus is thus protruded, covered with the inverted vagina, the fiindns 
merely clearing the external parts, while at other times the whole of 
the uterus depends several inches below the pelvis. With this dis- 
placement there is always very extensive displacement of the pelvic 
and abdominal viscera. 

The great vaginal hernia thus formed, sometimes contains the 
ovaries. Fallopian tubes, bladder, a large quantity of intestine, and 
elongated omentum. The viscera are sometimes so extensively dis- 
placed as to cause more or less descent of the transverse colon, stomach, 
and liver. In this last degree of protrusion the retentive power of 
the vaginal sphincter, perinseum, and all the ligaments is lost, and the 



382 



DISPLACEMENTS OF THE UTERUS. 



only support left is the greatly distended and elongated vagina, which, 
as a kind of sac, contains this great mass of diverse organs. 

Anteversions and retroversions without some flexion are not fre- 
quent displacements. These conditions until within a comparatively 
short time were all described as versions ; now, however, the distinc- 
tion between versions and flexions is recognized by the profession 
everywhere and is of great importance. In simple versions the uterus 
retains its figure, the fundus generally lying lower than the os, either 
before or behind the vagina. In anteversion the fundus falls for- 
w^ard upon the anterior vaginal wall, while the cervix points in the 
direction of the sacrum. It is a rare displacement. Retroversion is 



Fig. 111. 




Anteversion of the Uterus. 



the condition in which the fundus falls backward and occupies the 
cul-de-sac, while the cervix is turned upward and forward, more or 
less nearly approaching the symphysis pubis as it is longer or shorter. 
In both these displacements the position and calibre of the bladder 
and urethra are affected, as in the one the fundus is pressed down- 
ward upon the bladder and urethra, while in the other the cervix 
bears them upward. 

In flexions, which are always deformities, the cervix or body of 
the uterus is doubled upon the fundus, or expressing it differently, 
the fundus is bent backward or forward of the normal axis of the 
organ. Generally in flexions of the uterus the cervix is not much 



SYxMPTOMS. 



383 



displaced, but in some instances the fundus remains in position while 
the cervix is bent forward or backward. 

In anteflexions the fundus is bent forward and lies upon the blad- 
der and anterior wall of the vagina, while in retroflexions the fundus 
is turned backward and occupies the cul-de-sac below the vagina. 

There are several degrees of flexion in both varieties, some being 
bent very short, while in the others the flexion is slight. 

Some gynaecologists believe that slight anteflexion is the natural 
condition of the virgin uterus, and is consequently of more frequent 



Fig. 112 



:C" ^^X""^- 



/• .\ 



H ^: 







«,' 



Vv'-?.' 



^s^ 




Retroversion of the Uterus, showing the Fundus pressing upon the Eectum, and the Cervix 
encroaching upon the Bladder. 

occurrence and of less importance than any other displacement. I 
have no doubt of the correctness of this view of the subject, yet ex- 
treme anteflexion sometimes gives rise to great inconvenience and suf- 
fering. I quite agree with Dr. H. Webster Jones, of this city, when 
he says that *' retroflexion of the uterus is the most mischievous of 
all displacements and the most difl&cult to manage.^^* 

Symptoms. 
The symptoms of displacement of the uterus are not sufficiently 

"^ A paper read before the Chicago Gynaecological Society at the April (1880) 
meeting. 



384 DISPLACEMENTS OF THE UTERUS. 

distinctive to characterize one condition fiom another or even to 
enable us to decide whether there is displaeement or not^ 

Those displacements in which the utems remains within the pelvis 
manifest their existence by the influence they exert opon the nervons 
and vascnlar apparatus. 

The symptoms are for the most part those spoken of elsewhere as 
uterine symptoms, to which the reader is referred. 

In fact these forms of displacement, when the utems is in a healthy 
condition, do not give rise to any symptoms, and it is only when the 
uterus or some other of the pelvic oi^ans are diseased, that the pa- 
tient suffers inconvenience. All experienced gynaecologists meet with 
displaced uteri in which uterine symptoms do not exist* 

But when there is uterine hyperaemia, subinvolution, ordinary con- 
gestion, or inflammation — and one of these conditions nsnallj ante- 
dates the displacement — the patient will sufler from uterine symptoms. 

These remarks do not apply to protrusion of the nteros, for in 
some respects the influence of this condition is pecnliar. More fre- 
quently than otherwise the symptoms are entirely local. Locomotion 
is often not so much affected by extensive protrusion as by some form 
of version of the uterus. While I believe that tlie symptoms are gen- 
erally caused by the hypenemia of the uterus, and that this is the 
antecedent state of the viscus, there is no doubt but that the uterine 
disease is very much aggravated by the displacement, on account of 
direct pressure upon the nerves passing through the pelvis, and by 
changing the direction of the vessels, thus lessening their calibre and 
embarrassing the circulation in the organ. 

The pressure upon the sacral plexus causes sciatica, or upon the 
nerves of the anterior parts of the pelvis neuralgia of the anterior 
fiart of the limbs. The circulation in the veins carrying the blood 
from the uterus is retarded^ and congestion, with all its sympath^c 
accompaniments, results. 

Diagnosis. 

By physical examination there is very little difficnltj in tnafeing 
out a correct diagnosis, unless when complicated. In lapse or simple 
falling of the womb a finger in the rectum will easily reach the cervix: 
at the point where it presses upon that int<^ine. 

By this method the eer\^ix will be found just i ' 
it will l>e easily displaced upward and to the sid- 
be passed behind it and along its posterior wall. E _ina the 

finger will pass downward and backward to reach the cervix, when 



DIAGNOSIS. 385 

it win easily recognize the shape and size of that part of the organ. 
To introduce the probe it will be necessary to draw the cervix for- 
ward with the finger, when it will pass upward and forward. 

The retroversion or retroflexion will be easiest recognized by intro- 
ducing a flexible probe or sound. The point of course will pass in 
no other direction than downward and backward. When the sound 
is in the cavity, if we turn it, the fundus will be lifted up into its 
proper place. The movement of the uterus under the influence of 
the sound may be best observed by the finger introduced into the rec- 
tum. If, after the sound is inserted into the uterus to the fundus, 
we pass the finger into the rectum and place it upon the fundus we 
can accurately observe the process of replacement. AVith the sound 
in the uterus fixing that organ, and finger in the rectum, the diag- 
nosis between a small tumor and a retroverted fundus will not be 
difficult. The finger may be passed up over the fundus on the ante- 
rior wall of the uterus, and thus determine that the appearances are 
not caused by a small tumor which sometimes simulates the fundus. 
Anteversion may be diagnosed by the sound ; passing it up carefully 
it will pass forward and upward, and at the same time lift the fundus 
from its position on the anterior wall of the vagina. If there is a 
sharp flexion we sometimes have great difficulty in passing the sound. 
In retroflexion, w^hen this difficulty occurs, after passing the sound 
down to the flexion, the finger should be introduced into the rectum 
and the fundus lifted up enough to straighten the cavity so that the 
sound will pass. A finger in the vagina may be made to lift the 
fundus from the anterior wall of the vagina for the same purpose in 
cases of anteversion. 

There is generally very little difficulty in diagnosing prolapse, as 
the finger will easily recognize the cervix, and the sound will pass 
directly backward instead of upward or downward. One would 
suppose that protrusion would be the easiest form of displacement to 
recognize by physical examination, and so it is generally. Some- 
times, however, the shape, color, size, and consistency of the uterus 
are so changed by congestion, ulceration, and friction as to make it 
almost unrecognizable. 

By carefully inspecting the protruding part, however, we will 
always be able to find the mouth, through which the sound may be 
made to pass to the fundus. The catheter introduced into the bladder 
will generally pass downward and backward into the tumor. 



25 



CHAPTEE XXVI. 

DISPLACEMENTS OF THE UTEKUS, CONTINUED. 

Treatment of Displacements of the Uterus. 

Peeparatoey to speaking of the use of instruments for the sup- 
port of the uterus reposited from a state of displacement, it will be 
proper, in a cursory manner, to describe conditions in which they are 
not applicable, and to which we must direct our attention before we 
can succeed in their use. 

In cases of displacement where the vagina is sensitive, we will find 
any kind of pessary intolerable. Inflammation of the vagina and 
vaginismus are probably the most common conditions giving rise to 
the hypersesthesia which precludes the use of the pessary ; and when 
either of these morbid states are present, their removal is the first 
thing to be accomplished. 

AYe sometimes meet with undue sensitiveness of the perineum and 
lower portion of the rectum, rendering the use of some forms of 
pessaries entirely impossible. 

This sensitiveness is often the result of simple hypersesthesia ; but 
more frequently it is caused by inflammation and ulceration of the 
rectum, fistula, or haemorrhoids. 

Hypersesthesia from inflammation of the uterus, and especially in 
the acute and subacute forms, are incompatible with the use of pessa- 
ries. Simple hypersesthesia, similar to that found in vaginismus, is 
a not infrequent condition of the uterus, which forbids the applica- 
tion of direct support. 

Immobility of the uterus from old adhesions must be overcome, 
also, before we can venture upon pessaries. 

Perimetric inflammation in the acute, subacute, or chronic forms 
contraindicate the use of suj^port. 

It might be considered superfluous to mention these conditions as 
incompatible with mechanical support; but it has been my misfor- 
tune to witness efforts made, and persevered in, to replace a uterus 
that was displaced by inflammatory efiPusion, and was only a part of 
a great mass, all of which was supersensitive from the actual presence 
of subacute inflammation. Instances of this kind, of injudicious at- 



TREATMENT OF DISPLACEMENTS OF THE UTERUS. 387 

tempts lit restoration of the displaced uterus, are not confined to the 
practice of wliat might be termed ignorant physicians. We occasion- 
ally meet with them in the hands of the general practitioner who 
ought to know better. We cannot emphasize too strongly the in- 
junction not to make attempts to restore the uterus when they are 
attended by pain, or when there is any abnormal increase of general 
temperature or a rapid pulse. 

Displacements which are the effects of non- inflammatory effusions, 
as hsematocele or peritoneal dropsy, cannot be replaced with any 
safety until the cause is removed. 

It is seldom that mechanical support is devoid of peril w^hen the 
uterus is displaced by tumors. For the most part, when there is a 
tumor situated in any part of the uterine tissue of sufficient weight 
to displace the organ in any direction, we ought to abstain from the 
use of pessaries. That there are occasional cases in Avhich the patient 
may be made more comfortable by supporting the uterus and tumor 
I have no doubt, but I believe they are exceptional, and require the 
exercise of unusual skill to avoid mischief. 

Before resorting to permanent mechanical support the uterus should 
be habituated to replacement by manipulation, piledgets of cotton, 
oakum, or other soft material. It is true that experienced gynaecolo- 
gists, in favorable cases, are often able to adopt a pessary that may 
remain for an indefinite length of time doing no harm, but generally 
they are obliged to proceed cautiously and watch the effects before 
they can be sure that their instruments are profitably borne. I would 
again warn the inexperienced against repositing the uterus when it 
causes pain, or allowing an instrument to remain in the vagina when 
it produces suffering; and it would probably be equally proper to 
say, that in all cases the instrument should not only not cause pain^ 
but be attended with a sense of relief. 

The number of mechanical devices to replace and support the 
uterus is so great as to excite astonishment and skepticism in the 
ordinary observer. Almost every conceivable material has been em- 
ployed in their construction ; and while there are undoubtedly many 
contrivances which are merely the product of the imagination of the 
inventor and worthless, a large majority of them have some useful 
application. Almost every instrument of profitable fashion has a 
physiological as well as mechanical basis. It should, as far as pos- 
sible, be made to perform its functions in imitation of the supports 
employed by nature. While this remark may not be applicable to 



388 DISPLACEMENTS OF THE UTERUS. 

all kinds of mechauical supports that may be made available, it will 
apply to a great many of them. 

Another statement in reference to this formidable array of sup- 
porting instruments will not be out of place, and that is, a consider- 
able diversity of inventions will be found necessary to success. We 
cannot expect to succeed in all cases by any one instrument or any 
class of instruments; we are, therefore, fortunate in having the benefit 
of so much ingenuity in this direction. 

When the displacement is not extreme, much good may be done 
by frequent replacements by the hand or otherwise. 

Patients can often be taught to replace the uterus themselves. The 
knee-chest position will do a great deal toward correcting most dis- 
placements of the uterus. The assumption of this position is espe- 
cially useful in correcting lapse or falling of the organ, prolapse, and 
retroversion . 

Dr. Henry F. Campbell, of Augusta, Georgia, contributed an able 
paper on the genu-pectoral position as an important item in the 
treatment of displacements of the uterus. {Transactions of the Ameri- 
can Gyncecological Society, vol. i.) To make the position more effec- 
tive. Dr. Campbell has invented a small glass tube (figure, p. 216), 
which the patient can introduce into the vagina to admit the air. In 
this way he avails himself of the effects of gravity in removing the 
pressure of the abdominal viscera and of atmospheric pressure through 
the vagina. Patients who are taught how to effect these objects by 
position may sometimes relieve themselves, temporarily at least, of 
the pain and discomfort attending malposition. If, after having occu- 
pied this position for a sufficient length of time, they will carefully 
lie down on the side for several hours, the consequences will be more 
effective, if not more permanent. 

This position will often enable us to elevate the retroverted uterus 
by the fingers, which could not be replaced without the aid of instru- 
ments, and, in some instances, the introduction of instruments will 
Oe greatly facilitated by placing the patient in this position. 

Instruments. 

The instruments for sustaining the uterus in its restored position 
are used externally or internally, and some are partly external and 
partly internal. The external variety are usually termed abdominal 
supporters. 



SUPPORTERS. 



381) 



Supporters. 

Their main object should be to restore and retain the pelvis in a 
proper relation to the spinal column. They are made by connecting 
two pads or disks, one for the back and one for the abdomen, by two 

Fig, 113. 




Fitch Supporter, 



flat metallic springs extending over the hips on each side. The disk 
resting on the back is sometimes double or quadruple, the divisions 



Fig. 114. 



•OO^NVTM^Ji:^ 




London. 



being about four inches apart, one above the other, and connected by 
springs. These disks rest on either side of the spine, and by press- 
ing on it give it support. The anterior part is broad and placed just 



390 



DISPLACEMENTS OF TEE UTERUS. 



above the pubis. AVben properly placed, tliis instrument has a strong 
tendency to keep the patient erect. Shoulder-straps, to draw the 




^^??^?*^'W^^^ 



t3 



■5 SvYV»i^.^>-r 

Silk Elastic Body Belt. 



A^ 



shoulders backward, add to tbe efficiency of these instruments. The 
best of these external supporters are Banning's and Fitcli's (Lon- 



FlG. 116. 




Banning Supporter. 

don). An ela.«tic bandage properly made will, to a certain extent, 
perform the same service. 

Pessa/^ies. 

Instruments to be introduced into the vagina or uterus, upon which 
the organ may directly or indirectly rest and be thus supported in 
its natural position, are much more extensively useful and are adapted 
to a larger range of displacements. Pessaries are made of a great 
variety of materials and fashioned into very different shapes and 
sizes. 

The great numl^er and variety of pessaries lead to much confusion 
in considering the subject of their adaptation. There is so much 
difficultv in determiniuo' what each form of instrument mav be made 



PESSARIES. 



391 



to do that the inexperienced practitioner is often unable to see in each 
one tlie character of the case to which it is suited. His practice, 
therefore, instead of being rational, is often haphazard, an utter 
failure, and sometimes injurious. 

I have neither the time nor the desire to give an elaborate account 
of the different forms of pessaries, and the different cases to ^Yhicll 
they are adapted ; but, for the benefit of the student, I will endeavor 
to classify them, so that he may at least get some useful hints in the 
methods of using them. 

1st. The first class I will mention includes those pessaries which 
have for their points of resistance or support the vagina and perinseum, 
and I will term them vagino-perineal pessaries, because their shape 
is such that they are held in position by resting upon the perin^eum. 



Fig. 117 



Fig. 118. 





Smith's Pessary. 



Thomas's Modification of Smith's Pessary. 



and by being grasped by the vagina. They consist, for the most part, 
of modifications of Hodge's instruments, as the Albert Smith pessary, 
and those resembling it. It is large posteriorly, and narrow ante- 
riorly. The broad part surrounds the cervix uteri, while the narrow 
part lies in, and is retained in place, to some extent, by tlie anterior 
part of the vagina, the walls of which embrace it with some degree 
of firmness. 

But the instrument has a double curve on the flat. One curve 
enables the posterior part to rise behind the uterus and lift up that 
portion of the vaginal wall implanted in the posterior surface of the 
cervix, and thus draw the cervix backward and upward. The second, 
or perineal curve, adapts its concavity to the upper part (convexity) 



392 



DISPLACEMENTS OF THE UTERUS. 



of the perinseiim. It thus rides upon the perinseuni and supports 
the uterus, and rocks backward and forward with the different move- 
ments of the viscera above, when impressed by respiration, or other 
movements of the body. 

There are many pessaries that have these points of support. The 
second, or perineal curve, is a great improvement upon the earlier 

h Fig. 120. 





Gehring. Hemtt. 

forms of Hodge's pessary for some cases. It is admirably suited to 
retroversion when there is no considerable degree of laceration of the 
perinseum. 

There are some other pessaries that are retained in position by the 
vagina and perin^eum, as the globe, elastic disk, cradle pessary of 
Hewitt, and the anteversion pessary of Gehring, etc. 

Fig. 121. 




Zwank's Pessary. 

2d. Belonging to the second class of pessaries are those which are 
supported upon the ischiatic tuberosities, or rami, and may be 
called the ischiatic. An example of this variety is Zwank's pes- 
sary. It has two branches, resembling wings, that, after the instru- 



PESSARIES. 393 

raent is introduced, spread open, one on each side, resting upon the 
ischiatic bones. This instrument, expanding the vagina, lifts the 
uterus up, by virtue of the insertion of the vaginal walls into the 
cervix. It also affords a nearly flat, expanded surface, upon which 
the uterus may rest. It is very useful in cases of cystocele, when the 
anterior wall of the vagina prolapses to a moderate degree ; this pes- 
ary will frequently do all that can be desired for temporary relief, 
and not unfrequently it accomplishes a permanent cure. This instru- 
ment has but little support from the perinseum or vagina. 

3d. The third class of instruments have their bearings on the 
tuberosities or plane of the ischium and pubis. These are the vari- 
ous forms of rings : the round, oblong, or elongated, etc. The ring 
that is not curved on the flat side, if small, may, and often is, re- 
tained by the vagina, while the anterior segment rests against the 
pubis ; but when large, it extends to the three points above named. 
The same thing may be said of the small and large disk pessaries, 
whether hard or elastic. Of course, when the perinseum is present 
in its entirety, all these different forms of pessaries find more or less 
support upon it. 

4th. Still another class of pessaries, acting as levers, are partly 
suspended from behind or before, and rest upon the perinseum as a 
fulcrum. The intravaginal portion of some of these instruments 
have the retrouterine and perineal curves that belongs to the vagino- 

FlG. 122. 




Scott's Pessary. 

perineal class, but its anterior extremity is elongated, and to it is 
attached a tape or cord, that passes directly upward or backward 
between the thighs and upward to the waistband, to which it is at- 
tached. The posterior or retrouterine extremity, by pressing back- 
ward against the posterior wall of the vagina, elevates the whole 
uterus, and, carrying the cervix with it, throws the fundus forward. 
It is a very simple instrument, easy of application, and answers ad- 



394 



DISPLACEMENTS OF THE UTERUS. 



mirably in some cases of retroversion, lapse, and prolapse. Dr. Scott, 
of Woodstock, Canada, makes an instrument of iron or copper wire, 
and covers it with india-rubber tubing. The wire may be bent in 
any shape, and thus made to suit different cases. The ring part 
should be fashiofled to fit well behind the uterus, and the projecting 
part bent so as to pass down between the limbs and turn up along 



Fig. 123. 




Cutler's Instrument in Position. 



the sacrum ; to this end the string or tape is attached that fastens it 
to the waistband. Very little attention will enable the practitioner 
to adopt the instrument, and when once fitted the patient may remove 
and replace it. 

The two points to guard are the one behind the uterus and that 



SUSPENSION PESSARIES. 



395 



upon the periniieum. Without care there is some danger of getting 
too great pressure behind the uterus or on the perinreum. These 
may be avoided by changing the curves to fit the parts comfortably. 
Cutler's instrument belongs to this class, and is admirably suited to 
the purpose of retaining the uterus in position after it has been ele- 
vated from a state of retroversion. 

Suspension Pessaries. 

5th. These instruments have their resting-points outside the pelvis 
by fixed attachments to an apparatus around the waist. They are 
made in the forms of rings, cups, and stems, mounted upon a vaginal 
stem, which is connected with the outside attachment. 



Fig. 121. 



Fig. 125. 





The Dr. Mcintosh Natural Uterine Supporter. 



supporter Applied. 



The vaginal stem is sometimes immovably fixed to some metallic 
support outside, and when placed is supposed to rigidly confine the 
uterus in position. In other instruments the vaginal stem is sup- 
])orted by elastic cords, generally four in number, extending to the 
waistband. In cases of entire or almost complete loss of the peri- 
neum, this kind of support, as a temporary means, and calculated to 
give some relief until more radical measures can be resorted to, is 
sometimes useful. In very old patients, where senile atrophy has 
resulted in such extreme tenuity of the perineum and vaginal walls 
as to render them incapable of resisting the downward pressure of 
the superincumbent organs, these instruments may sometimes be made 
useful. They are not, however, the proper kind of pessary to employ 
when the perineum and vagina are in a condition to permit the use 



396 



DISPLACEMENTS OF THE UTERUS. 



of pessaries described io class 1st. I might pass the intrauterine 
stem pessaries without notice if I did not desire to condemn them as 
supports. I am willing to condemn them mildly, however, because 
they are used by a number of eminent and careful gynaecologists with 



Fig. 126. 



Fig. 127. 



Fig. ]28. 



1 1 





The Ring and Cup Attachments to Cutler's External Supporter. 

evident profit, and because, also, I have not had any extensive expe- 
rience with them. 

Temporary pessaries, of various shapes and sizes, are made of cot- 
ton and oakum. They are not often relied upon for the permanent 
support of the uterus. They are very convenient as a vehicle for 
medicinal applications to the uterus and vagina. 

Adaptation of Pessaries. 

Lapse or falling of the uterus is probably the least difficult dis- 
placement to treat successfully. It will frequently not be necessary 
to use a pessary. By relieving the hypersemia, hypersesthesia, and 
enlargement of the uterus, the depression will often be cured. For 
this purpose scarification, glycerin cotton, the local application of 
tincture of iodine, or iodized phenol, hot- water injections, sitz-baths, 
etc., persevered in for a sufficient length of time, constitute the proper 
course of remedies. If this is not sufficient we may resort to the 
Albert Smith or Emmett pessary, and keep it in the natural position 
until, through the freedom of circulation thus attained, the structural 
changes are removed, and the tissues of the uterus restored to their 
normal condition. 

Anteversion, 

The same remarks in reference to the removal of the hyperaemia 
and hyperaesthesia of the organ are applicable to this form of dis- 



1 
I 



RETROVERSION. 397 

placement as in falling of tlie uterus. When not very much displaced 
in this direction, it will seldom be necessary to resort to supports; 
but when the malposition is extreme we may very properly employ 

Fig. 129. 




Thomas's Anteversion Pessary. 

either Geh ring's, Hewitt's, or Thomas's anteversion pessary, any 
one of which must be used with the precautions mentioned above. 



Betr 



aversion. 



There are many cases of moderate retroversion, especially when 
the uterus is not unusually heavy, or sensitive, in which support is 
not called for. Patients will often have this kind of displacement 
without inconvenience, and I hold it to be an absurdity to interfere 
with this or any other form of displacement that does not give rise 
to symptoms. 

When the uterus is enlarged, sensitive, and strongly retroverted, 
we may justly consider that the venous circulation is interfered with, 
and that the correction of the displacement is an important if not an 
essential measure in the treatment. Even in such conditions as are 
here supposed, the restoration of the position is only one of the means 
requisite to secure success. The other conditions must be attended 
to in a thorough manner, until the shape, size, and consistency of the 
uterus are restored. 

In the worst forms of this displacement the uterus and tissues 
upon which it has for a long time exerted injurious pressure, will not 
at first tolerate an instrument capable of keeping the organ in place, 
and it will be necessary to use soft and temporary pessaries, as cotton 
or soft rubber instruments, until the complicating conditions subside, 
or are much improved, and then they must often be employed inter- 
mittingly in order to avoid harm. Dr. Campbell's method of re- 
placement by the knee-chest position as above described, will often 
be tolerated and beneficial when no instrument, of whatever material 
composed, can be borne. Sometimes frequent restoration will be all 



398 DISPLACEMENTS OF THE UTERUS. 

Ave need do toward restoring the uterus, while the other treatment is 
removing the cause or causes of the displacement. When there is 
no tenderness or other complication w^e can often at once introduce a 
permanent pessary ; but wdien Ave do this, Ave should carefully watch 
the case, and remove the instrument at the first warning given by 
pain or tenderness. Scott's, Cutter's, Albert Smith's, Emmett's, and 
Thomas's pessaries are all under certain circumstances useful and 
successful in retroA^ersion, and they afford a sufficient A'ariety from 
which to choose. 

The question of adhesions binding the uterus in a malposition 
scarcely comes up in relation with any other displacement, but in 
this it is one of A^ery great importance. Impaction is much more 
frequent, and is often mistaken for adhesion. It should be remem- 
bered that these adhesions are the result of inflammation, and gener- 
ally local peritonitis, and that this last-named condition is often 
present in a subdued degree for a long time after the effusion result- 
ing from it has hardened into a false membrane. 

This circumstance w^ill be a standing caution to the considerate 
practitioner. It Avill be easy by a little indiscretion, in our attempts 
at restoration, to arouse a more acute form of inflammation, and thus 
do much mischief. ^Yhen there is tenderness behind the uterus Ave 
cannot be too careful, indeed Ave should always wait when there is 
good reason to apprehend local peritonitis until CA^ery CA^idence of it 
has subsided. And this Avill generally require a long' time, CA^en if 
judicious treatment is employed. The repositor in such cases is a 
very mischicA^ous instrument, if it is not always a questionable one. 
Position and the fingers wdll nearly always be the best means to re- 
duce the retroA-erted uterus, as well as to make the diagnosis between 
impaction and adhesion. 

As a general rule it will be found that, AA^hen the patient is placed 
in the knee-chest position and tAvo fingers of one hand introduced 
into the vagina and two of the other into the rectum, the impacted 
organ can be lifted out of its false position Avithout giA'ing her much 
pain. When there are adhesions, hoAvever, this would be both painful 
and impracticable, and Ave must desist from the effort, and pursue a 
course of treatment calculated to cure the inflammation. 

Are there any circumstances under which we are justified in break- 
ing up these adhesions? I think not, and but few where it is advis- 
able to stretch them so as to permit the uterus to be replaced and kept 
in position by a pessary. From obserA^ations, frequently repeated, I am 
sure that the absorption and disappearance of them are frequent and 



RETROVERSIOxV. 399 

may be looked for after sufficient time, and that it is better to wait 
an unnecessary length of time for this to occur than it is to run any 
risk of awakening dormant mischief in the peritoneum or cellular 
tissues. 

When we are satisfied of the removal of these bands of lymph, 
eiforts to raise the uterus by posture and manipulation should be con- 
tinued for some time before using the cotton or soft ^ubber pessary. 

There are several conditions of the vagina and cervix uteri not yet 
mentioned that are calculated to embarrass the inexperienced in the 
successful application of the pessary in retroversion. When the pos- 
terior reflexion of the vaginal wall is short, and the cervix is placed so 
far back as almost to seem implanted into the end of the vagina, it is 
sometimes difficult to make a sure lodging for the pessary behind it. In 
that case I believe Scott^s instrument to be the best, because it can be 
bent to any angle or length, and retained in position by the external 
branch, so as to press under and behind the cervix witli much exactness. 

When the intravaginal cervix is very short, so that it will easily 
slip over the side or back part of the instrument, I know of none better 
than Scott's. It is certainly more easily adapted to, and kept in 
proper relationship with, the contour of the posterior part of the 
vagina and in constant relation with the cervix than any instrument 
which lies wholly within the vagina. 

Another very embarrassing condition is a strong inclination of the 
retroverted fundus to one side, with the cervix lacerated. When the 
uterus, thus twisted, is reposited, the instrument to be effectual in its 
bearing must press upon the vaginal wall on the side opposite to the 
induration of the cervix. A pessary, like the Albert Smith or Emmett, 
that finds its support entirely within the vagina, is very hard to ad- 
just, on account of most of the weight resting on the side instead of 
one of the ends, as in ordinary retroversion. 

When, in consequence of the shortening of one of the broad liga- 
ments, the cervix is strongly drawn to one side, much care will be 
necessary in placing an instrument so as not to make too much pres- 
sure upon the short side, and yet give the proper support. In all 
such cases there is good reason to fear that there is a lurking chronic 
inflammation in the ligament to which the cervix is attracted, which 
upon slight provocation will be aggravated and become acute. In 
adapting the instrument pressure upon the suspicious ligament must 
be avoided. The instrument should be so moulded as to make mod- 
erate traction upon the opposite side of the vagina. I say moderate, 
because forcible traction will not be borne, will be likely to give pain, 



400 DISPLACEMENTS OF THE UTERUS. 

and may possibly cause inflammation. And here again the skilful 
use of Scott's pessary has, in my hands, yielded the best results. Of 
course in this class of cases much care in moulding, placing, adapt- 
ing, and watching, will be indispensable to success in the use of this 
or any other instrument. 

The treatment of protrusion or procidentia is founded upon the 
three indications derived from the nature of the case. Eestore the 
perinseum, remove a portion or cause contraction of the hypertrophied 
vagina, and strengthen the relaxed ligaments. My own experience 
is decidedly favorable to the use of artificial support, and in a great 
many instances it will be practicable and effective. If the uterus can 
be kept in its proper place, the ligaments will contract and become 
more resistant, the vagina also diminishes in size, and if the perinseum 
is not partially lost it will assume its tone and relative form and po- 
sition. Such pessaries as may be made to sustain the organ without 
distension or pain are best adapted to the work. In fact the vagina 
ought to be distended as little as possible. They should not rest on 
the perinseum for support. Those supported externally are most suc- 
cessful when they can be tolerated. It is true that we sometimes 
succeed with globe pessaries, or disks, or lever, or ring pessaries. 
When the perinseum preserves much of its tone these instruments 
will fill the indications, but not otherwise. An air-bag globe of 
small dimensions at the upper end of a stem, will be tolerated often 
and prove very useful. The stem may be planted upon a shield that 
sets upon the external organs outside, and there retained by straps or 
bandages. This is a better way than to have a stiif rod reaching 
out and up to the top of the pelvis, or even up the abdomen. So 
long a rod under all movements of the body, bears with rigid fixed- 
ness upon the uterus. To fix the instrument at the vulva with a 
cord or band, places it where it is not subject to every form or great 
latitude of motion, while it does somewhat yield to internal pressure. 
The great trouble in the use of these instruments is that sometimes, 
after our best efforts to secure the results, they are not tolerated, too 
much sensitiveness of the parts preventing them from being worn. 
The pessary ought to be worn only when the patient is in the erect 
posture. It should be taken out after lying down and reintroduced 
before rising in the morning. Patience in selecting and modifying 
the shape of the pessary, with a clear view of the indications to be 
fulfilled, will sometimes enable us to succeed perfectly after having 
made a discouraging number of trials. We should study the case 
and learn why the instrument is not tolerated, and correct the diflfi- 



PROLAPSE. 401 

culty by changing or correcting the qualities of the instrument. It 
is remarkable how the vagina and perinseum will contract and become 
strong, when the uterus is kept in its place for some months. An 
ingenious use of artificial support will cure as many if not more 
cases than any other one sort of treatment. Astringent injections 
should be pei*severingly used in connection with the artificial sup- 
port. Saturated or very strong solutions of sul. acid, tannin, acetate 
of lead, etc., and decoctions of astringent bark, as oak, are the most 
eligible and effective forms for them. 

An efficient use of astringents would appear in some cases of ex- 
treme prolapsus to be sufficient to effect a cure. 

Dr. G. P. Hackenberg, of Rochester, X. Y., reports two cases in 
the Medical Record cured by what he calls packing the vagina with 
tannic acid, and says with reference to others : " I have treated with 
uniform success many lady patients who were subject to prolapsus 
uteri." Again he says : '^ I have hardly failed to control the most 
obstinate cases of prolapsus by this treatment." I here give a de- 
scription of his plan as given in his own language : 

*' A glass speculum was introduced iuto the vagina so as to push the 
uterus into its place. Through the speculum was introduced a metallic 
tube or syringe, with the end containing about thirty grains of tannin. 
With a suitable piston the tannin was now pushed out of the cylindrical 
tube against the uterus. The cylindrical syringe was then withdrawn, 
and the packing was neatly and effectually completed with a dry probang 
around the mouth and neck of the womb. After the packing was com- 
pleted the probang was placed against the tannin in order to hold it, and 
the speculum was partially withdrawn. The packing was now fully se- 
cured. The probang was next withdrawn, closely followed by the spec- 
ulum. 

*' The application of tannin held the uterus firmly and securely in its 
place, not by dilatation of the walls of the vagina, as in the case of the 
use of a pessary, but rather by an opposite condition — by corrugating 
and contracting the parts. The patient was promptly relieved by the 
application, and to her great astonishment was able to take long walks 
with comparative comfort. 

" The happy effects of this packing continued about a week, when 
symptoms of a relapse began to show themselves. Another packing was 
resorted to, with the same good effects. As we proceeded with the treat- 
ment of the case we prolonged the intervals of the application. At first 
they were made weekly, finally but once or twice a month. In two years 
the cure was completed, and I understand that the lady enjoys com- 
paratively good health since. 

26 



402 



DISPLACEMENTS OF THE UTERUS. 



" The almost constant application of tannin to the uterus not only 
overcomes the hypertrophy and elongation of the cervix, but I think 
even induces a slight atrophy of the parts. At no time did the patient 
suffer from this local treatment." 

Surgeons have generally in their operations addressed themselves 
to but one item in the case. One party operates upon the perinseum, 



Fig. 130. 




A. Cervix Uteri. E. Urethra. C C C C. Denuded Surface. 

restoring or lengthening it, more or less completely to close up the 
vaginal orifice, while another party lessens the diameter of the vagina 
itself and condensing its walls into cicatricial or undistensible tissue; 
and it is feared that the success of one procedure too frequently leads 
the operator to almost indiscriminate repetition of one kind of opera- 
tion, instead of acknowledging the importance of another and the 
necessity of meeting it with a different sort of surgery. Two, quite 
different in their nature, have been perfected and practiced by two 



PROLAPSE. 



403 



great representatives of female surgery, viz., Dr. J. Marion Sims and 
Mr. I. Baker Brown. Dr. Sims operates on the walls of the vagina. 
His operation consists in removing the epithelium of the mucous 
membrane, so as to denude the latter thoroughly, around a triangular 
space on the anterior wall of the vagina. The base of the triangle 
is at the cervix and the apex near the urethra. It is represented by 



Fig. 131. 




Showing the Uterus Entirely Protruded from the External Organs. A. Urethra. S. Os 
Uteri, c c cc. The Denuded Parts, with the Wire Sutures ready to approximate the Denuded 
Edges. 

Fig. 130. Dr. Sims recommends this to be done with the uterus 
returned into the vagina, but I cannot understand why the operation 
may not be more easily done with the uterus in its procident state. 
I have never done the operation, but I certainly would denude the 



404 DISPLACEMENTS OF THE UTERUS. 

membrane and insert the silver wires as they are seen in Fig. 131, 
then return the uterus, and afterwards bring the parts in apposition, 
and keep them so by twisting the wires. Dr. Emmet prefers the 
scissors to remove the membrane to the knife; he thinks there is less 
bleeding. The patient is prepared for the operation by thoroughly 
evacuating the bowels the day before, and administering, an hour 
before its commencement, half a grain of morphia. Chloroform ought 
to be given so as to keep the patient unconscious. Then placing the 
patient in position on her back, with the thighs well separated, the 
uterus is drawn down so as completely to invert the vagina, and held 
by a tenaculum in the hands of an assistant. The surgeon, by means 
of the scissors and tenaculum, removes the membrane, as represented 
in Fig. 130. This being done, and the bleeding having ceased, he 
may proceed to the introduction of the sutures, being careful to cause 
the needle to enter at equal distances from the margin of the cut 
surface outside of the triangle, pass well into the substance of the 
membrane, and come out close to the margin of the cut surface inside 
of the triangle, and in the same manner to dip under the other limb 
of the triangle. At the base they should be brought out every 
quarter of an inch in the cut, crossing from the longer limb of the 
figure. Drs. Sims and Emmet pass silk sutures through with the 
needle, and thus bring the wires through by attaching them to the 
thread. After this much of the operation is completed, the patient 
may be turned on the left side, and the vagina distended as for the 
operation for vesico-vaginal fistula, the parts carefully coapted, the 
upper two wires requiring great care to bring the whole of the elon- 
gated denuded surface together. The rest of the stitches from above 
downward may be drawn and twisted so that the denuded surfaces 
lie in even contact. The patient must be kept quiet by opium for 
ten days, the bladder emptied with the catheter every four or six 
hours, to prevent the urine from running on the wound, and the 
vagina should be syringed twice a day after the third day. Dr. 
Emmet advises us to remove the sutures on the tenth day, but says 
they may be allowed to remain longer. The sutures should be suffi- 
ciently numerous — every quarter of an inch — to keep the parts thor- 
oughly in contact, and they must be drawn tight enough to bring 
them well together without strangulating them. For direction as 
to twisting the wires, the reader is referred to the remarks, on this 
subject, in the article on vesico-vaginal fistula. They should be cut 
and arranged after being twisted, as in the operation for that acci- 
dent. This operation is applicable to cases where the hypertrophy 



PROLAPSE. 405 

of the vagina is very great, and the perineum entire but much dis- 
tended. 

Mr. I. Baker Brown's operation is applicable to those cases where 
there is a deficiency of perinseuni from laceration. It consists in de- 
nuding the posterior wall of the vagina an inch above the raphe of 
the perinfeum, and up the sides of the orifice two-thirds of the inner 
surface. The mucous membrane should be pretty thoroughly re- 
moved in order to give a solid substance for adhesion, deep stitches 
as for restoration of the ruptured perinseum passed, and the parts 
evenly adjusted. Fig. 132 shows the surfaces prepared and the 
sutures inserted. 

There can be no doubt but that cases might be cured by a combi- 
nation of these two operations, where either one alone would fnil. 

Fig. 132. 



Showing the parts, c c. Denuded and the Sutures passed. 

In such cases, Sims's operation should be done first, and after the 
patient is entirely recovered from it, the deficient perineum can be 
restored. 

In performing the operation of lessening the calibre of the vagina I 
have sometimes removed the mucous membrane from the whole area 
included in the triangle of the incision as represented in Fig. 130, 
and then burying the sutures in the submucous tissues across the 
whole face of the wound thus made. This I think forms a more 
solid cicatrix. Schroeder I believe does the same thing, his patch of 



406 DISPLACEMENTS OF THE UTERUS. 

denudation, however, is oval instead of triangular. Dr. Gillette has 
operated successfully for protrusion by passing sutures under the 
mucous membrane without denuding it. 

His operation simply condensed the walls of the vagina. On two 
occasions I have imitated him so far as to pass the sutures around 
a sufficient area, and draw it in like a puckering string of a purse 
without denudation. 



CHAPTER XXVII. 

DISPLACEMENTS OF THE UTEKUS COXTIXUED. 

Betroversion and Retroflexion of the Uterus during Pregnancy. 

The uterus is sometimes found retroverted or retroflected during 
pregnancy. When small during the first few weeks of pregnancy, 
its existence is not observed because it produces no inconvenience, 
and it is not until it grows large enough to partly or completely fill 
up the pelvis that anything is known of it unless discovered by ac- 
cident. If it is examined at such time, the os uteri will be found 
against the symphysis pubis, sometimes but little above the arch, but 
occasionally as high as the top of that junction. If the uterus is re- 
troverted fully, the mouth looks upward and forward ; if retroflexion 
exists, the os is still at the symphysis, but its opening is directed 
downward and forward. In this last case the cervix is bent upon 
itself at a sharp angle, the lower extremity as before remarked look- 
ing downward and forward, and the uterine extremity turned back- 
ward and downward. So that the difference in these two conditions 
consists in the bent state of the cervix, and not in the position of the 
uterus. The body of this organ has its axis reversed almost com- 
pletely, the fundus extremity running through the lower bone of the 
sacrum, while the upper extremity of the axial line passes out of the 
abdomen above the symphysis. The body lies in the hollow of the 
sacrum included in the peritoneal cul-de-sac between the vagina and 
the rectum. Both these canals are compressed, the rectum hard 
against the sacrum and the vagina up against the pelvic bone. The 
direction of the vagina is upward and forward instead of backward, 
its usual course. The finger cannot be made to sink deep into the 
vagina except behind the pubis ; in introducing, it turns upward and 
forward. The urethra runs up in close contact with the symphysis 
pubis, and is narrowed very materially by extension and pressure, 
so that it very imperfectly performs the function of a viaduct from the 
bladder. 

Causes. 

Although pregnancy usually corrects misplacements of the uterus, 
such is not alwavs the case, for this condition is sometimes a mere 



408 DISPLACEMENTS OF THE UTERUS. 

continuation of its unirapregnated position. It is well understood 
by accoucheurs also, that in the early months of pregnancy the normal 
position of the organ is depression, and that prolapse and retrover- 
sion are not unusual effects of recent impregnation. Under certain 
circumstances this last deviation is not corrected by the advance of 
growth in the organ. Where other causes co-operate, a distended 
bladder may aid in causing the uterus to assume and retain this posi- 
tion, as may also loaded intestines pressing upon the fundus and 
anterior face. These causes and perhaps others operate to bring 
about a gradual displacement, but there are some that cause the con- 
dition suddenly. It should be remembered that it is only at a cer- 
tain time that these sudden causes can produce the effect, and that is 
after the end of the third month and before the beginning of the fifth 
month. It is about this time that the uterus attains a bulk sufficient 
to partly or entirely fill up the pelvic cavity. If when it has at- 
tained this size a sudden impulse is imparted to the fundus and 
anterior face of the organ, the fundus may be crowded so low into 
the hollow of the sacrum as to reverse the axis. In this state the 
forces acting in favor of correction are feeble and may fail to bring it 
about. Strong abdominal pressure upon the intestines and bladder 
under tenesmus, falls upon the feet or breech, lifting heavy weights, 
and even severe sneezing and coughing, are occasionally causative. 
In the cases where the efficient causes are suddenly applied, the 
symptoms are acute and established at once. In the other cases the 
train of symptoms gradually make their appearance. 

Symptoms. 

When induced suddenly the patient is seized with great pain in 
the back, with a sense of weight upon the perinseum, constipation, 
retention of urine, tenesmus, dragging sensation in the loins, and 
often though not always, sickness of stomach and vomiting. If 
gradually established, the pains, constipation, and retention of urine 
are slowly established, requiring from seven to twenty-one days or 
more to render them intolerable. I knew a case caused by a woman 
riding all day in railroad cars without urinating. 

There are two important symptoms, viz., retention of the urine, 
and of the faeces; from these result most of the distress complained 
of. Great distension of the bladder and the terrible suffering thereby 
produced is the worst. The student should bear in mind that quite 
frequently this symptom is deceptive. The urine is constantly drib- 
bling from the meatus, and the patient thinks, and will say, she 



DIAGNOSIS — TERMINATION. 409 

passes plenty of urine. The fact of this constant slight discharge 
should cause us to suspect that the bladder is distended ; it does not 
occur when the bladder is empty ; it is not sufficient to prevent it 
from beino- distended. Indeed I do not now recollect anv con- 
dition but overdistension that causes it. Retention of fseces is not 
productive of so great trouble as the other, but is attended with more 
or less inconvenience. 

Great pelvic distress, with stillicidium urince, are almost character- 
istic of retroflexion or retroversion, when recent pregnancy exists. 

Diagnosis. 

This is usually not difficult. The first, a very important consid- 
eration, is the existence of pregnancy. Upon making vaginal ex- 
amination immediately upon introducing the finger it comes in con- 
tact with a tumor. The pelvis is filled up by it in the posterior and 
lower part so that the finger is directed upward and forward. Very 
high up the vaginal cavity is quite small from pressure, at its ex- 
tremity; in contact with the pubis is the os fincce, very firmly held 
in its place. The tumor is round, elastic, and smooth ; not so hard 
as fibrous tumors, more central than ovarian, and more uniformly 
round than extrauterine pregnancy. It may be ascertained in most 
instances, also, that the tumor is larger toward the sacrum than the 
symphysis. 

Te)Tiiination. 

When left to itself retroversion may terminate in abortion, when 
the contents of the uterus will be expelled and the symptoms thus 
relieved ; or the bladder may be ruptured, the urine being discharged 
in the peritoneal cavity, causing painful death ; or the uterus may 
be ruptured, and its contents discharged in the cavity of the peri- 
toneum, giving rise to fatal peritonitis ; or the foetus and its mem- 
branes may be surrounded by fibrinous material, the patient recover, 
and these substances remain there enveloped ; or, inducing local sup- 
purative inflammation, be discharged by exulceration. Sometimes 
the tenesmus becomes so great as, by the violence of the eiforts, to 
break through the posterior walls of the vagina and uterus, and dis- 
charge the contents through the vulva from this artificial opening. 
Inflammation sometimes arises without being initiated by any of these 
disastrous accidents, and less suddenly causes the death of the patient. 
I think there can be no doubt but that there are very rarely cases of 
spontaneous reposition, recovery, and completion of the term of ges- 
tation. 



410 DISPLACEMENTS OF THE UTERUS. 

The prognosis is unqualifiedly bad if left to nature, but equally 
favorable if intelligently treated at the proper time. 

Treatment. 

The main thing to be done is to replace the uterus. This can very 
generally be accomplished. The attempt should not be delayed, as 
the uterus is constantly increasing in size, and the impaction becoming 
more certainly greater, increasing the difficulties as well as dangers. 
To facilitate the replacement the bladder should be emptied by the 
catheter when practicable, and the fseces removed from the rectum. 
This takes away some of the obstacles. Sometimes the urethra is so 
tortuous in its course, and the walls compressed so completely to- 
gether, that a catheter will not enter the bladder. An elastic catheter 
will sometimes pass the obstruction when the metallic will not; which- 
ever we may use should be urged forward w^ith the utmost gentle- 
ness, bearing in mind the great danger of perforating the attenuated 
urethra. The patient should be placed upon her knees and chest, or 
on the left side, with the left arm behind her, the thighs strongly 
flexed, and the right drawn up close to the abdomen and thrown for- 
ward. She should be placed on a table or the edge of a bed, so that 
the genital organs are easily controlled by the operator. In this posi- 
tion we may often succeed in replacement by the hand alone. The 
right hand should be well lubricated, and all the fingers be intro- 
duced into the vagina, so that the palmar surface is turned to the 
sacrum. The tumor is thus pushed up very gently and slowly, with 
the pulps of the fingers pressed closely upon the face of the sacrum, 
as high as the hand may be made to reach. There are not many cases 
in which the fingers will fail to carry the fundus above the promon- 
tory of the sacrum. When thus elevated it suddenly starts up and 
assumes the normal position. If, however, the fingers do not reach 
high enough for this purpose, a collapsed gum-elastic bag or bladder 
may be carried up between the fingers and the uterus, and, when 
elevated as much as we can reach, the bag may be inflated sufficiently 
to raise the uterus high enough. I have succeeded in all the cases I 
have tried with this method, and I think, when the impaction is not 
so great as to preclude dislodgment, that it will almost invariably 
succeed. Some surgeons recommend the introduction of the empty 
bag into the rectum, and inflating it there, and pushing it up ; others 
introduce a drumstick, with the end cushioned and lubricated, into 
the rectum, and, pressing it against the uterus, elevating it in that 
way. Again, an instrument is used not unlike two drumsticks, some- 



TREATMENT. 411 

what curved, attached together. The attachment confines the ends 
very near each other. The end of one of the branches goes into the 
rectum, and the other into the vagina. Thus arranged they pass up 
and carry before them the uterus. These expedients are very sure, 
but rough, and not a very safe means of arriving at the results. I 
think as much force in a proper direction can be applied by the fingers 
and elastic bag as it is judicious to employ in such cases. There are 
other methods of proceeding, but I do not think it necessary to men- 
tion any other, as these will suffice when reduction is practicable. 

In all these efforts to elevate the fundus we may fail, and then we 
may evacuate the uterus. This can generally be done by passing a 
bent probe through the mouth of the uterus far enough to rupture 
the membranes, and permit the escape of the liquor amnii. This 
being done, abortion will soon ensue, I can conscientiously only 
mention, for I can hardly think the operation of puncturing the 
uterus with a trocar through the vaginal wall ever commendable or 
necessary. The cervix is probably hardly ever so inaccessible but 
that some form of bent instrument can be made to enter it. 



CHAPTER XXYIIL 

DISPLACEMENTS OF THE UTERUS COXTIXUED. 

Inversion of the Uterus. 

I^'TERSIOX is the turning of the uterus inside out, with the fundus 
down and the cervix up. a reversion of its surfaces and ends. It is 
partial or complete. When partial, the fundus is depressed in all 
degrees, from a mere indentation to a considerable protrusion through 
the cervix and os uteri. The depression of the fundus, or partial in- 
version, passes into complete when the whole organ, fundus, body, 
and neck, have passed through the mouth, and hang down below it. 
It presents a recent and a chronic form. The recent may be regarded 
as extending through the first two weeks ; after which, the circum- 
stances and condition of the uterus and patient become what they re- 
main in the future, however long it lasts. The uterus, in that time, 
has becii condensed by contraction and involution to such an extent 
as to make the case permanent and difficult of change, except to dimi- 
nution and further condensation. Inversion almost invariably occurs 
anterior to or at the time of the removal of the placenta, but several 
hours, and, in very rare cases, several days may elapse before it is 
complete and discovered : for it is quite probable that in these in- 
stances partial inversion or greater or less depression of the fundus 
had existed from the time of delivery. It is believed by different 
parties that there are two modes observed in the process of inversion. 
Sometimes the fundus is indented or depressed in the cavity of the 
body like the bottom of a "junk bottle," the depression rapidly or 
slowly increasing until it is completely down. At others, the whole 
of the fundus, and, more or less, the whole of the body, are firmly 
contracted, while the cervix remains flabby and relaxed. In this con- 
dition a slight amount of abdominal tenesmus will drive the con- 
tracted part down through the relaxed cervix; and thus initiated, it 
requires but a continued action of the fibres of the organ and abdomi- 
nal muscles to finish the process. The causes of inversion are not 
always obvious, as cases have occurred under circumstances when 
least expected from any discoverable reasons, and inversion fails to 
be brought about by circumstances that are usually enumerated as 
sufficient. We occasionally meet with instances that have no history, 



SYMPTOMS. 413 

and neither patient nor physician can give us a clear idea of the time 
or manner of the occurrence. Such a case was a subject of litigation 
in this city a few years since. And other cases are recorded in 
virgins, and consequently referred to congenital origin. In a large 
majority, however, we may trace the history back to accouchement. 
The predisposing causes are enlargements and partial or complete 
passiveness of a part or the whole of the muscular iibres of the uterus. 
These are the conditions in confinement at full term, or abortion or 
premature labor, also enlargement from hydatids, hydrometra, tu- 
mors, etc. When the uterus is thus enlarged and lax after a greater 
or less loss of its contents, traction on the cord or placenta, or con- 
tained tumor, or injudicious or accidental pressure on the fundus by 
the hand of some person, or the action of the abdominal muscles 
thrusting the contents of the abdomen downward upon that part of 
the organ, it may be inverted. It is possible, I think, also, that 
powerful, irregular action of the fibres of the uterus may cause the 
initiation and completion of the process of inversion. It is then 
said to be spontaneous. The weight of the placenta, or the contrac- 
tion to expel a polypus, may commence inversion, and even complete 
it. The irregular contractions that result in inversion may commence 
before the expulsion of the child. After the liquor amnii has been 
discharged for a long time, the uterus contracts to suit the inequali- 
ties of the foetal surface, the globular shape of the organ being re- 
placed by inequalities in a number of places. Much is yet to be 
learned on this subject. It would seem clear from statistics brought 
forward by Drs. AVest and McClintock that it is exceedingly rare, if 
it ever occurs, under good management of labor cases. It has not 
been encountered in patients confined in the London Maternity 
Charity, nor the Lying-in Hospital of Dublin in 140,000 cases. 
The student is not to consider from this that it is impossible for it 
to occur in the hands of the ablest of accoucheurs. 

Symptoms. 

Usually these are appalling in the extreme. Without warning 
the patient is seized with faintness, coldness of the extremities, sense 
of great prostration, rapid and very feeble pulse, oppression about 
the heart, copious perspiration, hurried breathing, often vomiting, 
ringing in the ears, and blindness. Soon these symptoms increase, 
until the patient lies in a profound state of collapse, indifferent to 
everything transpiring around her, or throwing herself in every di- 
rection in paroxysms of agony inexpressible. This condition of col- 



414 INVERSION OF THE UTERUS. 

lapse is not always the result of copious haemorrhage, but seems to 
be of Dervous origin. A shock not unlike that caused by severe 
accidents, as falls, strokes, etc. But, generally mingled with this 
sort of impression, there is profound exhaustion from loss of blood. 
From this state of collapse the patient may very slowly rally, until 
she enters a tedious and imperfect convalescence. Or, in the cases 
where the exhaustion from hasmorrhage is added to the great depres- 
sion of the shock, the patient may be overwhelmed, and in a hour, 
or very few hours, her sufferings end in death. Imperfect recovery 
from the great effects of the first shock may enable the patient to live 
for several days, and at last, in five to ten days, die. In case the 
patient recovers from the first symptoms, after some weeks she may 
regain a fair degree of health, and retain it, or even improve, until 
lactation gives place to ovulation, or until this last function super- 
venes upon the first. The first menstrual discharge is preceded by 
copious mucous evacuation, and when the menses begin they are 
more than ordinarily profuse, and generally before they cease amount 
to prostrating haemorrhage. This haemorrhage is repeated monthly, 
more frequently, or is continuous, while the leucorrhoeal discharges 
become very profuse. Functional derangement of other and im- 
portant organs enters the list of morbid impressions ; the bowels are 
constipated, the heart palpitates, the stomach cannot digest with its 
former vigor and completeness, the head aches, the eyes become 
weak; the disposition of the patient changes; the memory fails her; 
she is pale, cold, and anemic ; in short, she enters a decadence that 
is continuous, until, after several months, or a few years, she is ex- 
hausted and dies. Although this is the course usually pursued by 
cases of inversion, it must be remembered that there is a class of them 
in which the patients do not suffer even much inconvenience, and 
their condition is discovered only by accident during their life, or 
on the dissecting-table. 

Diagnosis. 

When the symptoms present themselves so as to awaken suspicion, 
the diagnosis of recent cases may be made out quite clearly, by the 
descent of a tumor into or entirely through the vagina, and the ab- 
sence of the uterine globe above the symphysis pubis. The diagnosis, 
after a few days or weeks have elapsed, and the case becomes chronic, 
is not quite so simple and ready. The tumor is felt in the vagina, 
and is more sensitive than polypus. It is easily surrounded by the 
fingers, and by introducing two fingers in the vagina to the upper 



PROGNOSIS. 415 

end of the tumor, the deprassion formed by the junction of the vagina 
and uterus may generally be easily surveyed. If this is not entirely 
satisfactory, the sound should be introduced into the vagina before 
the fingers are withdrawn, and, guided by them, be made to sink as 
deeply into this depression as it will go without too much force. If 
the uterus is inverted, the probe will not pass beyond the fingers any 
distance, but if the vaginal tumor be a polypus, the sound will pass 
up at some point some inches above the fingers into the uterine 
cavity. The operator may test the position of the uterus in another 
way, by introducing the finger high up into the rectum, so that the 
end may reach above the tumor, and retaining it there, he may pass 
a catheter or sound into the bladder, and approximate the two; if 
the womb is in place, its thickness will be perceived interposed be- 
tween the two, but if inverted, the extremity of the catheter can be 
brought down upon the finger, with nothing but the membranous 
walls of the bladder and rectum intervening. 

Prognosis, 

Xo more serious complication of labor can occur than inversion of 
the uterus. The danger is great and imminent ; in a considerable 
majority of cases proving fatal, the patient dies within a few hours. 
Mr. Crosse says : " In seventy-two out of one hundred and nine 
fatal cases, the patients died within a few hours, eight of the re- 
mainder within a week, and six more within four weeks; another at 
five months, the result of an operation which had an unsuccessful 
issue, one died at eight months, three at nine months, and the others 
at various pericnils of from one to twenty years. '^ ( West.) Death in 
the first place soon after delivery seems to be the result of rapid ex- 
haustion of the vital forces by the terrible shock to the nervous system 
and the profuse haemorrhage that often complicates it. Death in sub- 
sequent times, however remote in the chronic form, is brought about 
by impairment of the vital functions by the same means, operating 
more slowly but as surely. The patient dies from exhaustion in 
both forms. Accordingly, we find that while inflammation has 
something to do in affecting the issue in rare instances, those cases in 
which there is no uncommon haemorrhage or leucorrhoeal discharge 
last longest, and sometimes do not prove fatal at all, the patient en- 
joying fair health for many years. I know one patient, fifty-six 
years of age, whose uterus was inverted sixteen years ago, and yet 
remains in that condition, as I have verified by examination, who is 



416 INVERSION OF THE UTERUS. 

in the enjoyment of as good health as the majority of women of her 
time of life. 

Treatment. 

The management of recent cases will be the easier the sooner after 
the accident it is commenced. Its reduction is generally successfully 
accomplished within the first hour or two if intelligently attempted. 
It is more difficult as time elapses, but it should never be considered 
impracticable until proper and persevering efforts have been made. 
The first item for consideration and action is to dispose of an attached 
placenta when the uterus has not detached it before, during, or after 
its descent. If the placenta is wholly adherent, its attachment should 
in nowise be interfered with until the uterus is returned to its former 
position; but if it is partially detached, it should be immediately 
separated by gently ^^peeling'^ it off with the fingers. This instruc- 
tion has reference solely to the prevention or lessening the amount of 
haemorrhage. If the placenta is attached throughout, the haemorrhage 
will be trifling; if partially separated, the condition most likely to be 
accompanied with fatal hsemorrhage exists, — relaxation of the uterus 
and partial separation of the placenta. It is well known that suffi- 
cient contraction of the uterus will separate the placenta, and when 
not contracted enough to do so, it is in too lax a state- for us to desire 
its detachment. If the placenta is partially separated, the completion 
of it by the fingers, as in the case when included in the uterus, will 
enable and stimulate this organ to contraction, and thus to the sup- 
pression of the haemorrhage. I do not think the question of conve- 
nience of return, or the possibility of being foiled in the reduction by 
the continued attachment, should be entertained. The want of con- 
traction enough to throw off the placenta is an evidence of such pro- 
found inertia as to insure easy reduction of the uterus. 

It being decided what course to pursue with the placenta, imme- 
diate efforts should be made to revert. And before beginning these 
efforts, we should remind ourselves of some facts in the case that are 
apt to be lost sight of in the hurry and confusion of such an appall- 
ing occasion. One fact is, that immediately after the occurrence of 
the accident, the uterus is in the same flaccid condition in which it 
was incapable of resisting the action of the cause ; another is, that it 
soon begins to contract, becomes firm, and, consequently, more diffi- 
cult to affect by counter influences; and a third, that the more the 
uterus is stimulated, by handling or otherwise, the sooner and more 
firm the contraction becomes, and, consequently, the greater difficulty 
in reduction. 



TREATMENT. 417 

Xo operator has complained to us of the bulk belug too great to 
return, but all of the resistance caused by contraction. The experi- 
ence of Dr. Meigs is conclusive on this point. He found that upon 
attempting to reduce the size of the uterus, by squeezing it to expel 
the blood, he caused it to contract, and it became so hard as to resist 
his efforts to push it up within the os; but as soon as he pressed 
upon the fundus he would depress it, or rather elevate it, until, 
by continuing pressure, he made it ascend first into the body, and 
through it into the neck, and finally up to its proper place. Dr. 
White, of Buffalo, although he did not mention with the same dis- 
tinctness the effects of the two sorts of pressure, was enabled, by in- 
denting first and then following up the vantage, finally to push the 
fundus up the same way through the os and body of the uterus after 
he had in vain tried to reduce it by squeezing, etc. Dr. AThite's case 
was reduced in this way eight days after delivery. And I must be 
allowed to express the opinion, that it increases the difficulties in re- 
cent cases of inversion to try to lessen the bulk of the uterus. A 
great bulk indicates a flabby, reducible state, and is favorable to suc- 
cess instead of otherwise. Do not squeeze the uterus to lessen its size 
in these cases. 

The two cases I have referred to, of Drs. White and Meigs, so in- 
telligently and deliberately observed, and so clearly described, fur- 
nish us with more intelligible means of arrivinoj at correct ideas of 
the steps by which inversion of the uterus is reversed, than any I am 
able to find on record. They both concur in showing the usefulness 
of one hand in the vagina to steady the uterus, and direct the force 
applied to the fundus by the other hand, and the injurious effects of 
compressing the body of the organ. The most appropriate mode of 
operating in recent inversion, therefore, is to introduce the left hand 
into the vaoina behind the uterus, while with the fiuo^ers of the right 
the fundus is indented, and gently, but steadily and perseveringly, 
reverted entirely above the os and cervix, until it assumes the globu- 
lar shape and proper position above the symphysis. If the fingers 
of the right hand cannot be used to advantage, or are too weak to 
accomplish the desired elevation, we may use an instrument resorted 
to by Dr. White, a large elastic rectum bougie, or by Dr. Beers, 
shaped like the end of a walking-cane, with a round smooth head 
upon a staff. The indentation and elevation may be more efficiently 
effected by this latter instrument, perhaps. 

The fact cannot be too forcibly impressed upon our minds, in un- 
dertaking this operation, that gentle firmness is the proper expression 

27 



418 INVERSION OF THE UTERUS. 

for the force to be employed. Perseverance, instead of violence, is 
both more certain, successful, and secure, in overcoming the resistance 
of muscular fibre anywhere. This is especially true with the uterus, 
the strongest muscle in the body. As nearly as may be, we should 
act in the absence of uterine contractions. During and after the 
time we are attempting the return of the organ, the strength of the 
patient must be supported by stimulants, tonics, and nutrients. 
Brandy will, perhaps, serve best to restore the circulation and heat ; 
it may be aided by the use of the aromatic spirits of ammonia and 
laudanum. In addition to the stimulant and supporting influence 
which laudanum exerts, it allays the irritable condition, so frequently 
present, of the stomach, the uterus, etc. After the urgency of the 
symptoms has passed by, the tincture of iron, quinia, beef essence, 
and nutritious diet generally, will be necessary to restore the im- 
paired condition of the vital energies. The energy with which the 
stimulants are to be urged during the shock must be regulated by 
the urgency of the danger. Large doses of brandy, laudanum, and 
spirits of ammonia will not only be borne, but often be called for to 
meet the symptoms. 

The Treatment of the Chronic Form 

Is palliative and curative. The palliative is for the purpose, as 
far as possible, to check the drain which is so constantly exhausting 
the patient, to support the system as well as we can, and to use any 
other means suggested by the circumstances for the relief of distress- 
ing symptoms. 

The haemorrhage is from the mucous membrane of the uterus, its 
outer surface as it lies in the vagina, as also the profuse mucous dis- 
charge. I think much may be done to moderate, if not stop, these 
evacuations by astringents introduced into the vagina, so as to sur- 
round and lie in contact with the uterus. Pledgets of lint, saturated 
with the persul. of iron, passed up into the vagina, and allowed to 
remain on the bleeding^ surface of the uterus until the bleeding ceases, 
will be of great service. The tinct. ferri chlorid. on lint is an excellent 
application for the same purpose. Other astringents may be tried in 
the same manner. If these should fail, the vagina may be tamponed 
fully with cotton, dipped in astringents or not as the physician may 
think best. Severe paroxysms of haemorrhage should be carefully 
treated in this way until they terminate, it being desirable to save as 
much blood as possible. It is not necessary to suggest to the intelli- 
gent reader the necessity of rest in the horizontal position. Between 



TREATMENT OF THE CHRONIC FORM. 419 

these paroxysms the patient should use astringent injections of con- 
centrated strength, saturated solutions of alum, acetate of lead, tan- 
nin, etc., with a view to condense the mucous membrane, and render 
it less vascular, and in this way abate the urgency of the losses. The 
tinct. ferri. chl., one part to four of water, twice or thrice a day, will 
have an efficient astringent effect upon the uterus. When the organ 
extends through the vulva, it is irritated by contact with the limbs 
and clothing, and it is very desirable to return it into the vagina, and 
keep it within that cavity. The gum-elastic air-pessary, supported 
by a T bandage, will keep it in the vagina, and may render it more 
easy of a radical cure, by reduction or reversion. I would urge the 
attendant to personal attention to this treatment, to such an extent, 
at least, as is necessary to have it efficiently tried. Veiy few pa- 
tients have the intelligence to appreciate the importance of it, or to 
know when proper trial of it has been made. 

The radical treatment has for its objects either a restoration of the 
organ or its amputation and removal. So far as we can judge, 
although both operations are attended with danger, that of amputa- 
tion the more. And I think it clearly the duty of the practitioner, 
when driven to a choice between the two, to give preference to at- 
tempts at restoration. We have not only greater safety as an argu- 
ment in favor of it, but successful restoration reinstates the patient 
in all her sexual capacities, while amputation, if not disastrous in 
other respects, renders her forever sexually neuter. It is to be hoped 
that before long the operation of amputation will be regarded as un- 
justifiable, because of the certainty of restoration. Great improve- 
ment in our means and the mode of effecting this must be made, 
however, before this conclusion can be reached. There is no longer 
room for doubting that restoration of the inverted uterus occurs spon- 
taneously. I think it is proven by the case of Dr. Hatch, published 
in Dr. Meigs's Obstetrics. The case of Madame Beauchardat, pub- 
lished by Baudelocque, is also, I think, conclusive on the point of 
restoration. Other cases, less clearly and circumstantially reported, 
may be found scattered through medical literature for the last cen- 
tury. There are two methods, if they may be so denominated, that 
have been successful in reducino^ chronic inversion of the uterus. Two 
representative cases are published in the American Journal of Medical 
Sciences for July, 1858 ; one by Professor White, of Buffalo (it was 
his second case), and one by Dr. Tyler Smith, of London. It will 
be observed, by examining the reports of these cases, that the res- 
toration began by the cervix passing through the os uteri first, then 



420 DISPLACEMENTS OF THE UTERUS. 

the body, and fioally the fundus. This is different from what I think 
is the common mode of restoration in recent cases. The operation 
for reversion in Dr. White's second case was completed, we are led to 
suppose, in something more than an hour, and at one sitting. The 
uterus had been inverted five months. Dr. White operated by in- 
troducing the hand into the vagina while the patient was in' a state 
of anaesthesia from chloroform, squeezing the uterus so as to lessen 
the size as much as possible, and at the same time pressing the organ 
upwards by means of the large rectum bougie. Success followed a 
somewhat ])rotracted manipulation. The uterus was restored by the 
lips of the OS uteri beginning to fold outward, and the neck to pass 
up through this opening, next the body, and afterwards the fundus. 
There is nothing in this case said about the fundus being indented 
from beginning to end. This is no more than might be expected by 
considering the anatomical circumstances. The fundus and corpus 
uteri are firmer and more solid than the cervix, and hence less likely 
to yield to the same amount of force. The force applied to the fundus, 
when the organ is strongly pressed upward, acts more efficiently upon 
the cervix than any other part, from the fact that the vagina, attached 
all around the mouth, has not merely the effect of resisting the up- 
ward pressure of the uterus, but, being upon the outer surface, it ini- 
tiates and keeps up the funnel-shape expansion of the os necessary to 
permit the other parts to pass through it, as well as to draw it down 
over the part entering it from below. 

I believe that, in some respects, this is the best manner of operating 
for immediate restoration, yet one thing done seems to me to be 
superfluous, if not mischievous, viz., the squeezing the uterus. Dr. 
Sims recommends that the uterus be supported by one hand above 
the pubis to prevent too great extension upon the vagina. While the 
uterus is being pushed up from below, the cup-shaped cavity formed 
by the inverted cervix may be felt if we forcibly press the fingers 
down into the pelvis from above over the pubis. This manipulation 
affords us valuable aid in forming our diagnosis, while it gives the 
opportunity of assisting in the reversion. The great thing to be 
gained is the commencement. After the neck is one-half reverted 
the restoration proceeds with more rapidity and ease than before until 
complete. A better instrument than the bougie used by Dr. White 
would be a cup on a strong handle, large enough to safely lodge the 
fundus of the uterus. Dr. White now uses what he calls the re- 
jjositor. The figure shows its action with sufficient clearness to re- 
quire no extended explanation of its use. The steps in the operation 



TREATMENT OF THE CHRONIC FORM, 



421 



for immediate restoration are, first to introduce the hand into the 
vagina, and, embracing the uterus with it, hold the organ steady, with 
the fundus and cervix nearly parallel with the axis of the superior 
strait; second, place the fundus of the uterus in the cup of the 
instrument held by the other hand, and then press gently upward, 
increasing the firmness of it until it is as great as the parts will bear 
without violence, and continuing it with such force until the parts 
yield and f)ass up. The time required may be considerable, and it is 
an object to continue it for a long time, increasing the pressure so 
slowly as not to be perceived, except by comparing it at considerable 
intervals. The patient should be under the influence of chloroform 
to insensibility, and placed on her back, with the limbs widely sepa- 
rated across the bed, and with the hips very near it; or, what would 



Fig. 133. 



Fig. 1:54. 




be better, an operating table of convenient height, about two feet wide 
and five long. Greater facility would be afforded for attendants by 
such a table. The surgeon should kneel or seat himself in front of 
the patient, so as to have free use of both hands and perfect command 
of the parts. 

The second mode of restoring the inverted uterus, as practiced by 
Dr. Tyler Smith, is to apply the force so gradually as to require 
several days for the completion of it. The uieans used were, first, 
the frequent introduction — I think twice a day — of the hand into the 
vagina to squeeze the uterus; and, second, to keep a gum-elastic air- 



422 DISPLACEMENTS OF THE UTERUS. 

bag distended in the vagina, which constantly pressed the fundus 
upward, certainly, however, with no great force. He succeeded in 
restoring a uterus that had been inverted for fifteen years. With 
proper apparatus I should very much prefer this gradual method, as 
requiring less violence, being less hazardous, and perhaps less painful. 

A sufficient number of cases have been successfully treated by this 
means to justify giving it a fair trial. Having succeeded in three 
cases in reducing with the elastic bag, I am more favorably impressed 
with its efficiency than Dr. White seems to be. The reduction was 
effiicted in from five to eight days, without giving the patient pain 
enough to interfere with her sleep, or causing her any serious incon- 
venience. Each day showed advances; the first, relaxation of the 
rigid neck ; the next, shortening of the displaced uterus ; and each day 
after exhibited gradual improvement until the restoration was found 
to be complete. I am convinced that in many, if not most, of the 
simple cases of chronic inversion the reposition may be accomplished 
by this method, and I would certainly try it before resorting to the 
more hazardous and more painful plan of Dr. White. Success with 
the elastic bag, however, requires a careful study of each case, and a 
watchful adaptation of the means. The kind of instrument is of 
much importance. The best shape, perhaps, is quadrilateral. It 
should be strong enough to bear considerable pressure without mate- 
rially altering its shape, and furnished with a tube and very tight 
stopcock. The instrument should be distended with water instead 
of air, as there are few that will not permit air to escape in greater 
or less quantities. The chances of success will be increased by a firm 
and well-shaped perinseum to support the pressure, and by its own 
elasticity adding to the efficiency of the instrument. When the peri- 
nseum is deficient, we may compensate it by well-adjusted mechani- 
cal support. The more firm the tissues of the vagina the better. 

The instrument should be introduced in an empty condition, and 
placed well back in the vagina, and the water forced into it until 
moderately distended. We must then carefuly examine the relation- 
ship between it and the uterus, and see that the latter is pressed up- 
ward in the direction of the axis of the superior strait. If this is not 
the case, we may be able to place the uterus in the right position by 
moving it with the finger. If this cannot be done, the bags should 
be emptied and changed until right. If the shape of the instrument 
is not properly adapted to the vagina, it should be replaced by another. 
By exercising due care in selecting and adjusting the instrument, we 
shall be able to get the force exerted in the right direction. When 



TREATMENT OF THE CHRONIC FORM. 423 

satisfied that the instrument is properly adjusted, we should inject 
water into it, and distend it as much as the patient can bear without 
decided pain. It will not be necessary to remove it more than once 
in twenty-four hours, but it ought to be examined in reference to the 
degree of distension, and if it should continue tense, and the patient 
feels no more discomfort from it, we ought to inject more water 
until the patient experiences slight uneasiness from the pressure. 
Once in twenty-four hours the water may be allowed to escape, and 
the instruments be removed, the vagina cleansed, and the parts thor- 
oughly examined. If we are producing any impression on the rigid 
cervix, the relaxation will be perceptible by the facility with which 
the uterus will move upward. The instrument should be carefully 
readjusted and again distended. On the second removal of the bag 
I think, usually, we may expect to discover decided progress in the 
process of restoration. I do not believe it judicious to manipulate 
and squeeze the uterus, with a view to lessen the blood in it, every 
time we remove the elastic bag, and would sedulously abstain from 
anvthino^ of the kind, believino; that the reaction after the withdrawal 
of the hand would engorge the vessels of the organ. The daily re- 
moval of the instrument, cleansing of the vagina, and readjustment 
must be continued until the uterus resumes its proper position, or 
until we find we cannot succeed by this plan. Judging from my own 
observation, and the cases I have seen recorded, I should expect suc- 
cess to follow between the fifth and the eighth days. But efforts may 
be continued much longer than this if necessary. As soon as the 
fundus has passed into the cervix, it will spontaneously resume its 
proper position, because the resistance to its doing so is removed; but 
if this should not occur, a rectal bougie may be placed against it and 
sufficient pressure exerted to rectify it completely. 

The pressure of this elastic bag when properly managed is just 
the kind desired, and the degree may be made very considerable. 
When the bag is of the right size and. form the uterus is pressed upward 
in such a manner as to place the vaginial attachments upon the stretch, 
and cause them to draw open the cervical cavity, and this tension is 
increased by the dilatation of the upper portion of the vagina in every 
direction. It thus acts as a dilator as well as repositor. And although 
the degree of pressure upward is not so great as may be made by the 
repositor of Dr. White, or by the hand, its steadiness of action, and 
the great length of time it may be continued, more than compensates 
in the end for its lack of violent force. We all are acquainted with 



424 DISPLACEMENTS OF THE UTERUS. 

the efficiency of moderate but long-continued traction upon fibrous 
tissue, in cases of long-standing dislocation. 

I will here present a case which has recently come under my ob- 
servation : 

December 24:th, 1878. — Mrs. M., Irish, aged twenty-six years, was 
brought to me with inversion of the uterus, which had taken place at 
the time of her first labor, fourteen months before. I obtained a 
very imperfect history of the case, but so far as I could learn nothing 
unusual occurred during pregnancy, and when the labor began the 
patient was in the enjoyment of robust health. The first and second 
stages of labor were normal, and together lasted six hours. During 
the. third stage haemorrhage was alarming, and the succeeding pros- 
tration very great. The patient could give me no intelligent account 
of the mode of delivering the placenta, or of the duration of the third 
stage. The only recollection of it was that she suffered from great 
pain and weakness. The accident was not discovered at the time, 
and when, after the lapse of some weeks, the attention of the prac- 
titioner was called to the unusual condition of the contents of the 
vagina, he said : " She must have a polypus or something else/' He 
either was not aware of what had occurred or did not wish to have 
the true condition known. 

Astringent injections were used and stimulants and tonics given. 

The patient gradually rallied, and during the first year was seen 
by a number of physicians, and many opinions were expressed and 
methods of cure tried. No benefit resulting from treatment, she came 
under the care of Dr. White, of Bloomington, who recognized the 
true condition of the patient, and made a very judicious and prolonged 
effort to reduce the uterus by the forcible method and failed. He 
then advised her to visit me for further treatment. 

When she arrived she was very anaemic and exhausted. She was. 
constantly discharging blood and mucus, and at the time of her 
menses flowed profusely. There was great tenderness and sensitive- 
ness of the vagina, uterus, and lower portion of the abdomen. The 
pulse was weak and about one hundred to the minute. She had a 
poor appetite and was obstinately constipated. 

An examination confirmed the diagnosis of Dr. White. The 
vagina was very capacious, and depending from its roof was a small, 
very firm uterus. The involution seemed to have been carried be- 
yond the ordinary degree. It was in a state of hyper-involution. 
It was completely inverted. The labia could be felt forming a thin 
border, completely surrounding the cervix, with the likeness of a 



I 



TREATxMEXT OF THE CHRONIC FORM. 425 

fringe, the edge pointing upwards. The uterus was so firm and 
condensed that it resisted every effort to elevate it. It could be 
drawn down somewhat, bringing with it a pouch of the upper wall 
of the vagina. There was considerable sensitiveness of the iliac and 
hypogastric regions, but no tumefactions, induration, or other evi- 
dence of the products of inflammation. A mild cathartic was ad- 
ministered, followed by the tincture of iron and quinine, and on 
Christmas day the treatment for reduction was commenced. An 
elastic bag, four inches long, and when distended three inches in 
diameter, with a tube attached, was selected as the main instrument. 
When collapsed this bag presented a quadrilateral shape, larger in 
the centre, and slowly tapering towards the ends. I selected a sac of 
this shape because it filled the vagina from the vulva to the bottom 
of the fornix, and when introduced one of the faces reached the 
fundus in such a manner that the organ would not easily slide over 
its sides. As the bag was slowly distended the fundus produced a 
depression in which it was firmly retained when the sac was filled. 

I introduced this bag, while empty, so that it lay on the posterior 
wall of the vagina, and carefully adjusted the dependent fundus so 
that the body was in a line with the axis of the superior strait. 
Water was slowly injected until the distension produced a sense of 
discomfort. The distension was kept up for twenty-four hours, 
when the water was permitted to flow away. The instrument was 
removed and cleansed, and again replaced and filled. The first time 
it was removed an evident softening of the cervix was noticeable, and 
the body could be pressed slightly into it. From day to day the 
softening and dilatation became greater, and upon the removal of the 
instrument advance was ascertainable. Upon removing the bag, on 
the seventh day, I found that the uterus was in a state of complete 
inversion, and all progress seemingly lost. With the finger, how- 
ever, I could easily press the fundus entirely into the dilated cervix, 
thus assuring myself that the work of reduction was almost complete. 
A more careful adjustment and careful distension of the bag were 
effected, and on the removal of the instrument on the eight day it 
was found that the fundus had mounted to its normal position. The 
sound was introduced two and a half inches. This patient improved 
in strength and became more comfortable from the commencement 
of the treatment to the end. After the first three days she was up 
during a part of the day, and on the seventh and eighth was about 
her room, and, in addition to keeping her room in order, gave her 
child all the attention it needed. 



426 DISPLACEMENTS OF THE UTERUS. 

I have no doubt that she was perfectly truthful in her assertion 
that the treatment gave her no inconvenience except at the time and 
for a few moments each time after the adjustment of the instrument. 
There was no time when I felt the least uneasiness about the effects 
of the pressure, or was under the necessity of giving anodynes for 
the relief of pain ; nor did the presence of the instrument prevent 
the free and comfortable evacuation of bladder and rectum. In 
fact, the patient improved from the time she was placed under 
treatment. 

Notwithstanding the important improvements of Dr. J. P. White, 
.who deserves more credit for his success and teaching in inversion 
than any other man, and Dr. Tyler Smith's success in the use of the 
gum-elastic bag, there will yet remain cases in which the uterus can- 
not be restored to its natural position and relations. Inversion, com- 
plicated with several fibrous tumors of the body or fundus, will 
resist ordinary methods of reduction, and, no doubt, cases in which 
the causes of difficulty cannot be precisely discovered will occasion- 
ally be found unmanageable. What shall be done with such? The 
necessity for any operation that involves the life of a patient, already 
in great danger, should be clearly determined by the circumstances of 
the case and with ample counsel. If the patient's health is growing 
worse and her strength being exhausted by great discharges or per- 
sistent inflammation, relief should be attempted at all hazard. If, 
however, the woman is enjoying fair health, or if the symptoms that 
usually harass her after the accident of inversion are improving, any 
operative procedure beyond efforts at reduction is not justifiable. 

In cases where restoration is proven to be impossible by proper, 
prolonged, and repeated efforts, or the uterus is so enlarged by morbid 
growths as to make it obviously useless to try reduction, and the con- 
ditions demand relief, amputation is the last resort. In a resume 
found in the American Journal of Obstetrics , xlugust, 1868, trans- 
lated from the German, we have fifty-eight cases reported of ampu- 
tation of the inverted uterus; eighteen terminated fatally, forty 
recovered. This is a large mortality, but probably the fatality will 
become proportionately less as all the conditions of the operations 
are improved. The methods of amputation now practiced are essen- 
tially three : 

1. Ligating and allowing the ligature to remain until it cuts 
through. 

2. Ligating to prevent haemorrhage, and then amputating below 
the ligature with the knife, scissors, or ecraseur. 



TREATMENT OP THE CHRONIC FORM. 427 

3. Passing the ecraseur or galvano-cautery wire through the sub- 
stance of the cervix without ligating. 

The ligature, when properly applied, effectually prevents haemor- 
rhage, but it is very likely to cause inflammation, also a very formid- 
able occurrence, and one which is the frequent cause of death. Or 
if it remains long enough to cause sloughing even of the amputated 
stump, there may arise toxaemia, resulting from the absorption of the 
putrid substance. The ecraseur avoids this latter difficulty, but I 
should fear it would be an insecure guarantee against haemorrhage in 
all cases. Dr. Thomas Hay, of Philadelphia, reports, in the Medical 
and Surgical Reporter, December 2d, 1871, a case in which amputa- 
tion was successfully performed by the ecraseur alone. Dr. McClin- 
tock, of Dublin, applied the ligature for forty-eight hours, and then 
removed the uterus by amputating with the ecraseur in the groove 
formed by the ligature. Practical demonstration is the only reliable 
guide in important operations ; we are not supplied, however, with 
enough examples of success by any one procedure to justify us in 
making a positive choice between them. 

It will not be difficult to get access to the cervix for the purpose of 
applying the ligature or amputating. This may be done by drawing 
the organ down to the vulva with vulsellum forceps. 

The galvano-cautery is better than all the above methods of ampu- 
tation. 

The wire applied as an ecraseur, heated to a dull red color, and 
drawn slowly through the cervix, will do away with the dangers of 
haemorrhage, and leave no sloughing surface from which sepsis may 
be generated. 



CHAPTEK XXIX. 

DISEASED DEVIATIONS OF INVOLUTION OF THE UTEEUS. 

The uterus is very much hypertrophied by the processes of gesta- 
tion, so that after its contents are expelled by labor, the organ weighs 
from one and a half to two pounds. An atrophizing process, called 
involution, serves to reduce the organ to its original conditions in size 
and weight. 

Involution is a physiological change, as much so as evolution ; but 
not unfrequently disease invades the tissues and renders it abortive : 
1st, causing it to be temporarily ^^ delayed ;" 2dly, to fall short of 
completion after it has been commenced ; or, 3dly, to proceed entirely 
beyond the limits compatible with the healthy functions of the uterus, 
reducing it below its usual weight and size. 

I mean by the term "delayed involution" to designate a condition 
of the uterus in which this process does not begin for a number of 
days — from ten to fourteen — after parturition. 

The contractions which immediately succeed and continue after 
labor, by interrupting the circulation in the substance of the uterus, 
initiate that process, and by the end of a fortnight it is half finished. 
Should these contractions be rendered inefficient, involution is at a 
stand, the uterus remains large, the circulation too great for safety to 
the patient, and sufficient to keep up the nutrition in the muscular 
fibres, which are still capable of a good degree of energetic action. 
For a number of days the uterus is felt to be as large as a child's 
head, above the pubis, and not very firm. 

Causes. 

The most common cause of this delay is inflammation attacking 
the substance of the uterine walls. The inflammation may be acute, 
and the patient's suffering such as to demand attention, or so slight 
as to pass without much notice. Cases of puerperal metritis, for a 
week or ten days immediately succeeding delivery, not unfrequently 
prevent this enlarged condition of the organ. 

Another cause which probably operates to prevent involution is 
atony of the uterine muscular fibres. The contractions are feeble, 
and so inefficient as to delay for a long time, and render very slow. 



SYMPTOMS — PROGNOSIS. 429 

the early stages of involution. Too early assumption of the erect 
posture and undue exercise on foot, keeping the bloodvessels of the 
uterus distended unduly, and thus overcoming the muscular contrac- 
tion, are not unfrequently the causes of delayed involution. 

Si/mptoms. 

The symptoms of delayed involution, separate from the inflamma- 
tion, are not always very well marked. Weight, heat, and aching 
in the back are the most frequent, especially if inflammation is the 
cause. There is always great danger, however, of a very alarming 
symptom while this state of the uterus exists, and that is flooding. 
Where the delayed involution is dependent on atony of the muscular 
fibres, haemorrhage is sure to take place if the patient exerts herself 
considerably. As the first indication of any seriously wrong con- 
dition of the uterus, the patient is suddenly seized with copious haem- 
orrhage, which subsides under the influence of rest, cold, and astrin- 
gents, but suddenly and unexpectedly recurs without adequate cause. 
When suspected, the diagnosis is not difficult by an examination with 
one finger of the right hand per vaginam, w4iile with the left hand 
pressure is made above the pubis. The uterus, thus examined, is 
found to be as large as immediately after labor is ended. 

The soft, uncertain condition of the uterine globe will not always 
enable us to discover it by placing a hand upon the lower part of the 
abdomen alone, but by including the organ between the two there will 
be no danger of mistake. If the organ retains sufficient firmness to be 
easily distinguished above the pubis by the single hand, there w^ill be 
but little danger of haemorrhage. The local distress will then be the 
only indication of the necessity of a diagnostic examination, when the 
greatly enlarged condition will be easily detected by the examination 
above directed. The fingers may be easily made to enter the mouth 
of the organ and move the whole mass, while the hand above will 
easily recognize the movement, or the hand above may be made to 
press it down upon the fingers below. 

Prognosis. 

There is imminent danger of serious, if not fatal, haemorrhage. I 
have known as many as two cases of sudden fatality from flooding 
after the seventh day from the time of labor. It is always a serious 
condition, and should be watched diligently and treated efficiently. 
Even in cases where the delay is caused by acute inflammation great 



430 DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS. 

haemorrhage may take place, although not so likely as when caused 
by muscular atony alone. If the delay is for a very considerable 
length of time the involution is pretty sure not to be completed, but 
the uterus remains in a state of subinvolution for an indefinite time. 
Very often the causes which effect delays continue to act, and finally 
produce subinvolution. 

Treatment. 

The treatment depends upon the causing conditions. If there is 
inflammation of the uterus the antiphlogistic measures necessary to 
combat it are demanded, with counter-irritation, fomentations, etc. 
Should atony, unattended with inflammation, exist, ergot in large 
doses is demanded imperatively until ergotism is brought about. 

I usually give 5ss. pulv. secale corn, in infusion, every half hour, 
until contractions are brought about. When this is done the effect 
of the drug may so subside that it will be necessary to administer it 
again in twelve or twenty-four hours, until all disposition to relax 
has passed away. When atony and the inflammatory condition 
coexist, which may be known by the tenderness, fever, and haemor- 
rhage occurring together, the ergot and other treatment should be 
combined. Haemorrhage is not likely to come on until after the 
inflammation has pretty well subsided, and aids usually in removing 
the last of it. 

I subjoin two cases as representatives of the two conditions of the 
uterus, and the mode of treating them : 

Case I. This case was furnished me by Dr. S. Wickersham, of this 
city. He was called to Mrs. E., an Irishwoman, aged twenty-eight, 
in her fourth labor. May 7th, 1863, 4 o'clock p.m. She had been in 
labor, attended by a midwife, for the most of the day. At 1 o'clock 
A.M. of the 8th pains had entirely ceased, from atony or exhaustion 
of the uterus. Constitutional symptoms began to show the necessity 
for relief. The forceps were used, and the child was delivered. The 
placenta was delivered in due time without difficulty, and the uterus 
contracted well. Haemorrhage not more than usual. The pulse was 
unusually frequent at and after the time of delivery. The labor was 
followed in two days with puerperal fever, in which the uterus and 
peritoneum were both involved. Up to the 20th she had improved 
very much, so as to be considered by the doctor as convalescent. In 
the early part of the day sudden and violent haemorrhage prostrated 
the patient to what was at the time considered a moribund condition ; 
but by active stimulation and external warmth to her cold extremi- 
ties she rallied, and appeared to be slowly recovering. At 6 o'clock 



TREATMENT. 431 

P.M. on the 2-4th the haemorrhage returned with " terrible vio- 
lence," and she was thought again to be dying. Notwithstanding 
the most energetic use of stimulants she could hardly rally from this 
last attack. On the 26th, in consultation with Dr. Wickersham, I 
found the patient so prostrated as to leave but little hope of her re- 
covery. Suspecting that the uterus was in a state similar to w^hat is 
found immediately after delivery, I insisted upon making an exami- 
nation, which was resisted by the patient and friends. Through the 
kind perseverance of Dr. Wickersham I was permitted to do so. The 
uterus was so flaccid that I could not discover it above the pubis 
until after iutroducins^ the fing^er into the vaccina and movino^ it 
about, when the fundus could be felt as high as the umbilicus, with 
the reo^ular o^lobular form. The mouth and cervix were laro^e and 
flabby, and easily admitted two fingers. After this examination the 
indication seemed plain. Large doses of ergot were given in addi- 
tion to the stimulating and supporting treatment. Hemorrhage was 
very slight on the morning of the 27th. She continued to improve 
slowly until the 9th of June. At 5 o'clock a.m. the haemorrhage 
returned, and lasted until 10 o'clock a.m., but in so moderate a de- 
gree as to produce but little effect upon the patient. I was not in 
attendance after the first consultation, and could not trace the steps 
of condensation, but after the 9th of June the haemorrhage did not 
recur. 

It will be seen that on the twelfth day after confinement dangerous 
haemorrhage took place ; that it again returned on the sixteenth day 
after delivery to a very alarming extent ; and that after the liberal 
use of erorot the haemorrhao^e returned but slio^htlv. It should be 
noted, also, that the cessation of the haemorrhage was sudden, and 
probably resulted from faintness, and that it returned as soon as the 
arterial reaction amounted to any considerable degree. The faintness, 
doubtless, was the cause of stoppage in both attacks before ergot was 
given, but the haemorrhage was effectually checked by contractions 
caused by the ergot. 

Case II. Mrs. E. is the mother of nine children. She is thirty- 
three years of age, and a German Jewess. Of robust, almost athletic 
make and habits, she always enjoys excellent health. In the last 
three confinements she has almost lost her life from loss of blood, both 
before and after the delivery of the placenta. I attended her in the 
eighth labor, the last before this one. There was nothing peculiar in 
it until after the child was delivered, the labor having lasted but 
about four hours. The pains were ordinarily vigorous and propul- 



432 DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS. 

sive. The liquor amnii was not evacuated until ten minutes before 
the head was distending the labia. After the child was expelled the 
uterus did not contract thoroughly. It seemed large and rather soft. 
This state lasted for half an hour, when a feeble contraction detached 
but did not expel the placenta. From this time hseraorrhage became 
excessive. I waited for half an hour — using friction, kneading, and 
pressure over the uterus, with application of ice to the vulva — for 
contraction of the uterus and expulsion of the placenta, but although 
there were occasional pains, thev were so feeble as to produce no effect 
u23on the haemorrhage. About this time the ergot I had sent for 
arrived, and I gave immediately o^s. in a little wine and water. 
Fearing the prostration which was rapidly coming over the patient, I 
introduced my hand into the uterus, grasped the placenta, and irri- 
tated the organ by moving the whole around in it. This brought on 
contractions enough to expel my hand and placenta, and deluge the 
bed with coagula and fluid blood. Yery soon the ergot began to 
act, and the haemorrhage ceased. I give this description of her eighth 
labor to show her predisposition to inertia uterina. As the ninth 
labor approached, I determined I would administer the ergot as soon 
as the parts were well dilated, and the head began to pass the os 
uteri. I was sent for at 8 o'clock p.m., June 30th, 1864, to attend 
her. I found the pains active and the os uteri fully dilated, and the 
membranes distending the labia. I at once gave her ergot 5ss. in in- 
fusion, making her swallow the ergot as well as the water. This was 
repeated in half an hour. By this time ergotism was fairly estab- 
lished. In three-quarters of an hour from the time I arrived the 
child was born, and in a few minutes the placenta was expelled from 
the uterus into the vagina whence it was removed. No haemorrhage 
followed. The uterus was well contracted. I considered her condi- 
tion very favorable, and at the end of another hour took my leave. 
Her condition for the first forty-eight hours was in no respect unusual, 
except that the lochial discharge was rather free. From this time I 
saw but little of her until the 10th of July. I returned from the 
country at 5 o'clock p.m., and found she had been flooding since 
early in the morning, not very greatly, but suflQcient to begin to pro- 
duce faintness. The uterus could be felt above the symphysis pubis 
as large as a child's head, and not very hard. I ordered cold to the 
pubis, and twenty drops of aromatic sul. acid in some water every four 
hours, expecting soon to have the haemorrhage checked ; but to my 
surprise, at 8 o'clock on the 11th, the haemorrhage still continued, 
being but slightly moderated by the means used. I now ordered two 



i 



SUBINVOLUTION OF THE UTERUS. 433 

teaspoonfiils of vin. ergoti every half hour until the haemorrhage 
ceased. But the nurse said that the " second dose put her in so much 
pain and caused such large clots of blood to come from her that she 
dare not give it again." The haemorrhnge ceased entirely from this 
time until the afternoon of the 13th, when it returned with considerable 
violence. The ergot was again given, and from this time forward 
the patient had a favorable convalescence, and is now in the enjoy- 
ment of good health. 

Subinvolution of the Uterus. 

To understand subinvolution in its principal bearings it will be 
necessary to discuss more at length the subject of involution itself. 
I think that involution of menstruation plays a much more impor- 
tant part in the structural diseases of the uterus than we have been 
inclined to attribute to it. It will not be considered irrelevant there- 
fore to take a glance at the subject, as involution presents itself in 
menstruation as well as in pregnancy. 

In the healthy uterus, what may be called trophic changes are con- 
stantly going on, from the beginning of menstruation to the meno- 
pause. The circulation of the uterus is increased in quantity from the 
cessation of one menstrual crisis to the beffinnino- of the next. Dur- 
ing the days of the flow the ajfflux of blood subsides to the lowest 
amount. 

From the cessation of the monthly flow there is an increase of 
solid tissue in the uterus until the beginning of the next menstrual 
flow, during which time there is involution or an elimination of solid 
tissue, notably the mucous membrane of the cavity. 

These processes of afflux of blood and accretion of tissue may be, 
and often are, prolonged, and pass into what is known as congestion 
of the uterus. 

When this round of monthly changes is interrupted by pregnancy^ 
processes similar in character on a much larger scale are accom- 
plished. The afilux of blood and increment of tissue do not attain 
their maximum until the end of gestation. The contents of the 
uterus is expelled, and then begin the changes called involution, the 
object of which is the elimination of the superfluous circulation and 
solid tissues, until the uterus returns to its menstrual status. 

The prolongation or arrest of this is subinvolution. 

Post-partum involution is no doubt initiated, if it is not completed, 
through the agency of muscular contractions. The large fibres which 
have been strong enough to expel the foetus, placenta, and mem- 

28 



434 SUBINVOLUTION OF THE UTERUS. 

branes, continue to contract, and in doing so compress the vessels, 
and thus cut off at once a large quantity of the blood circulating in 
the uterus. As a result of this some of the fibres are deficiently sup- 
plied with nutritive elements, and undergo fatty degeneration. The 
granular fatty material is absorbed and the general bulk of the organ 
diminished. Further contraction is thus rendered possible, when 
more fibres disappear in the same way until the process of involution 
is finished. The length of time required is, I think, much longer 
than is generally supposed, seldom intone month, often not in three 
months, and sometimes morbid causes prevent it from ever being 
accomplished. The uterus then remains more vascular and bulky 
than normal, or is in a state of subinvolution. 

In both post-menstrual and post-partum subinvolution this simple 
vascular condition does not continue for any great length of time. 
Hypersemia is often a mischievous condition, and sooner or later 
causes changes in the organization of the viscus in which it exists. 
In subinvolution there is at first hypersemia, with hypertrophy of 
the fibrous, vascular, and nervous tissues. These solid portions of 
the organ degenerate, not into a fatty substance that may be absorbed, 
but into fibrous tissue of a low organization. 

Either as the effect of exudation from the capillaries, or the slow 
absorption of the more vitalized molecules of the muscular fibres, or 
both, there comes to be an undue amount of connective tissue. The 
transition from the more muscular and highly vitalized state of the 
uterus to this one of induration may be accomplished in a few months, 
or it may require the lapse of years. When it is complete many of 
the symptoms that indicated the state of recent subinvolution are re- 
placed by others of a different kind ; especially do the bloody dis- 
charges from the uterus become less than normal. 

Subinvolution is a term then which embraces different pathological 
conditions; or, perhaps, it would be expressing the facts better to say, 
that several distinct pathological conditions of the uterus result from 
subinvolution. This last statement will apply equally to menstrual 
subinvolution as to the post-partum. 

We ought not to lose sight of the fact that all the physiological 
and some of the pathological changes occurring in the uterus are to 
a great extent coincidental with, if not the consequences of, the changes 
going on in the ovaries, — the organs that dominate the whole genital 
system. 

During ovulation the menstrual hypertrophy takes place ; at the 
time of the discharge of the ovum menstrual involution occurs. 



CAUSES. 435 

During the development of the ovum in the uterus, ovarian hyper- 
trophy is going on ; at the time of the expulsion of the ovum the 
processes of involution begin. 

It is quite probable that after the ovum is inclosed in the uterus 
and gestation established, the uterus is prompted bv ovarian influence 
to the enormous physiological and anatomical changes which go 
forward in it, up to the perfection of foetal life, and afterward govern 
the processes of labor and involution. It is certain that the ovaries 
do not return to the condition in which they were, before conception, 
until pregnancy has terminated, nor in fact during several months 
of lactation. 

While the generative functions of the ovaries are held in abey- 
ance by lactation, — or, if I may express it differently, while the 
ovaries are engaged in the reflex duties of sustaining lactation, — they 
do not return to their former condition. According to my obser- 
vation, involution of the uterus, ovaries, and vagina is not complete 
in persons who nurse their children until the ordinary term of lacta- 
tion has elapsed. Looked at in this way I think involution will 
present different features than when viewed from a more circum- 
scribed standpoint. We will attach more importance to the influence 
of the nervous system, exerted through the ovaries. 

The term and process of involution extend to the changes observed 
in all the genital organs, the lacteal glands, the ovaries, uterus, vagina, 
Fallopian tubes, uterine ligaments, and perinseum. How much 
more susceptible to the effects of morbid causes, therefore, must be 
all the contents of the pelvis in the hypersemic, hypersesthetic, 
and hypertrophic conditions during the time involution is going on, 
and how readily the affections of one pelvic organ will influence the 
condition of all the others. 

The genital organs constitute a separate and, in some respects, inde- 
pendent physiological system, governed by special nervous centres, 
all bound together and dominated by the ovaries, under all the 
physiological changes accompanying pregnancy, labor, and invo- 
lution. 

Causes. 

Any morbid causes that prolong the processes of involution may 
arrest the process entirely. The character of the labor may have this 
effect. If it has been tedious enough to produce great nervous ex- 
haustion, the uterine fibres will be powerless to conduct the changes 
necessary to a speedy and perfect involution. 

If the cervix is lacerated or badly contused, the consequent inflam- 



436 SUBINVOLUTION OF THE UTERUS. 

matory reaction interrupts involution for a greater or less length of 
time, or perhaps for all time. 

Inflammation of the body of the uterus resulting from severe labor 
or exposure may do the same thing. General and special causes not 
dependent upon labor often act so as to bar the completion of involu- 
tion. Some of these causes are general debility ; that is an impover- 
ished condition of the blood, lack of nervous energy, a want of the 
powers of endurance, cold acting through the nervous system upon 
the circulation of the uterus post-partum or during menstrual con- 
gestion, the excitement of anger, fevers, or the depression of fear, etc. 

Special causes operate through the genital nervous centres upon 
the uterus directly, as venereal excitement from unnatural lascivious 
practices, coition during or just before menstruation and within 
the month after labor, libidinous literature, and exciting exhibitions. 

Diseases in the surrounding organs by keeping up nervous and 
vascular excitement, ulceration, fissure, and hsemorrhoids of the 
rectum, specific vaginal inflammation, laceration of the perinseum, 
urethral and vesical inflammation, displacements of the uterus, etc., 
all tend to produce this effect. 

Frequency of its OccurrenGe. 

Without exaggerating the importance of subinvolution, I believe 
it would be correct to say, that more of the chronic congestions of 
the uterus originate in puerperal and menstrual subinvolution as 
here explained than in any other one condition. 

By taking the puerperal and menstrual involution as a funda- 
mental and almost constantly present condition of the pelvic organs 
for a basis, I think we can better explain the mode of operation of 
exciting causes in producing chronic diseases than by any other 
hypothetical method. Certain it is, that there is no other organ in 
the body so prone to lesions of circulation and their consequences as 
the uterus, and that the reason why this is the case must reside in the 
anatomy and functions of the organ. 

It is an organ, the very nature of whose condition is one of un- 
ceasing fluctuation of vascularity and nervous susceptibility. 

Symptoms and Diagnosis. 

The general symptoms of subinvolution are in no respects distinc- 
tive. All the reflex symptoms spoken of as uterine symptoms, or 
symptoms of uterine disease, may exist in patients the subjects of this 



SYMPTOMS AND DIAGNOSIS. 437 

condition ; neither do the local symptoms guide us with certainty to 
a correct diagnosis. In the earlier months of subinvolution, in fact 
for an indefinite term, metrorrhagia is a frequent symptom, and in 
some instances continues as long as the disease lasts. It represents 
what may be termed the vascular stage of subinvolution. In a great 
many cases of subinvolution after a certain time, which also is very 
indefinite, the bloody discharge from the uterus becomes less copious, 
and occasionally entirely ceases. This diminution of the flow indi- 
cates the supervention of the fl"brino-plastic stage, or a condition in 
which the vascularity of the uterus is diminished while the solid 
tissue is increased. Leucorrliosa is generally present or absent under 
the same conditions that govern the flow of blood. 

Diagnosis. 

The diagnosis must be made up from the history and physical 
examinations. If the sufferings of the patient date from an abortion, 
or labor at full term, and in addition to the general and local symp- 
toms of uterine disease there is or has been for months too copious 
or too frequent menstrual discharges, or haemorrhages intervening 
between the regular periods, the presumption is that there is subin- 
volution, or at least that the symptoms were at first those of that 
condition. One of the most constant appreciable conditions of sub- 
involution is the large size of the uterus. This may be ascertained 
by bimanual examination and the introduction of the sound. 

When the uterus is lifted up by the fingers in the vagina, the 
fundus will be more easily felt by the hand above, and the sound 
will pass farther beyond the normal depth into the cavity than 
when the organ is of a normal size. 

The shape of the uterus is generally still that of the post-partum 
organ. It is proportionately thicker through its antero-posterior 
diameter. The enlargement, therefore, is diiferent from enlargements 
from other conditions. 

The shape is often modified by retroflexions and lacerations of the 
cervix. When retroflexed without laceration, the fundus and body 
are much larger proportionately as compared with the cervix. When 
the cervix is badly lacerated, it is enlarged. The appearances in this 
respect are sometimes deceptive when the labia are widely separated. 

When examined through the speculum the color is deeper than 
natural, the mouth patulous, the cervix large and often ulcerated. 
Generally, also, there is copious albuminoid mucus hanging from the 
OS uteri, sometimes of an amber color, from the admixture of pus- 



I 



438 SUBINVOLUTION OF THE UTERUS. 

corpuscles. When the cervix is lacerated, the mucous membrane of 
the cervical cavity is exposed, and presents a papillary or fungoid 
appearance. 

These are the appearances in the vascular stage of subinvolution. 
After this has passed, and the fibrino-plastic change has taken place, 
the cervix and body will feel hard to the touch; sometimes the indu- 
ration in such cases is very marked indeed. While the induration is 
generally uniform with respect to the cervical circle, and extends en- 
tirely around, at other times it is confined to one of the lips. Then 
the color is often not increased, and the surface is smooth and covered 
with cicatricial tissue instead of granulations or fungoid bodies. 

Prognosis. 

During the vascular stage of subinvolution, and while the hyper- 
trophied fibres of the uterus retain their muscular character, we may 
hope to succeed in restoring the normal condition of the organ. We 
must remember, however, that metrorrhagia, indicating great vascu- 
larity of the uterus, is no evidence that the fibres are not greatly 
changed or replaced by non-contractile tissue, and consequently the 
prognosis should be guarded. The longer the time the case has 
lasted, the greater the probabilities are that the fibres are replaced by 
connective tissue. 

After this vascular and hypertrophic condition of the muscular 
fibres have passed away, and there has been extensive fibrino-plastic 
deposit in the walls of the uterus, the probabilities of a cure are very 
remote. The uterus is then hard, inelastic, its tissues permeated by 
few vessels, and the nerves diminished, if not entirely absent. 

Treatment. 

The preventive treatment should begin during pregnancy. Every 
means necessary to place the patient in good health, both generally 
and locally, must be resorted to, — exercise in the open air on foot, 
if at all practicable, and domestic employment or exercise of like 
character. 

The habits of the patient should be regulated with a view to the 
development of the muscles of the entire body, while her diet should 
be abundant in quantity and of the most nutritious quality. 

It is not my purpose at this time to do more than to call the atten- 
tion of i\\Q> obstetrician to the subject of preparing patients for the 
great task of passing safely through labor. During labor everything 



TREATMENT. 439 

sliould be conducted with the view of preserving the integrity of all 
the soft parts, because, as before intimated, damage to any of the 
parts concerned in labor is pretty sure to be followed by subinvolu- 
tion. 

The more physiological a labor is, and the more skilfully conducted, 
the less the tendency to subinvolution. 

After labor complete contraction should be brought about, and 
maintained, not by mechanical irritation, but, if need be, by the use 
of ergot and vaginal injections of hot water. These latter will stimu- 
late the pelvic nerves and prompt the uterus to contraction, and by 
their cleansing effects promote the repair of every damage that the 
soft parts may have sustained. Above all things, a sufficient amount 
of absolute rest must be enjoined to insure recovery of the viscera. 

The most assiduous attention should be especially given to control 
all inflammations that follow labor. 

From the immense number of gynaecological cases traceable to 
labor, it is to be feared that some of the modern innovations in the 
practice of midwifery are not improvements. 

More attention and care in conducting patients through cases of 
abortion and premature labor should be practiced than is usually done. 

Abortion is looked upon by the patients themselves as a small 
matter, and it is very difficult to induce them to give the necessary 
time and care to themselves. Physicians know that it is a more dis- 
astrous process than labor at full term, and they will do service, there- 
fore, by enforcing proper measures, whenever it is practicable, to 
insure good recovery from it. 

After the patient has passed from the hands of the accoucheur to 
those of the gynaecologist the treatment of subinvolution will be gov- 
erned by the conditions in each case. Until the muscular fibres have 
lost their power of contraction, ergot, strychnia, quinine, and iron, 
with good, nutritious diet and exercise in the open air, will be the 
general remedies most efficacious. 

Ergot, given in moderate doses, perseveringly administered, is a 
very powerful means of supplementing the natural contractions. It 
is not applicable to cases, however, where there is inflammatory ex- 
citement in the uterine substances, and should be withheld until, by 
alteratives, counter-irritants, and rest, that condition is removed. 
When this inflammatory condition is not present the ergot and tonics, 
judiciously administered, will co-operate well in the accomplishment 
of the general result. However, gynaecologists do not often see these 
cases until the contractility of the fibres has been very much im- 



440 SUBINVOLUTIOX OF THE UTERUS. 

paired, if not entirely lost. In most cases, even thus late, the ergot 
and tonics will have some good effect. 

In chronic cases the local treatment is of prime importance ; and 
the first thing to be thought of is the removal of any cause- of in- 
creased vascularity that may be found associated with it. If there is 
laceration of the cervix or perin&eum it should receive attention. If 
there is misplacement it must be corrected, so that the outgoing cir- 
culation may be as free as possible. VTlien these conditions are cor- 
rected we may begin a system of local treatment that will remove the 
congestion, and cause the absorption of the fibrino-plastic deposits. 
The use of glycerin tampons and hot-water injections will be found 
applicable and beneficial in most cases. The glycerin cotton should 
be applied about every third day, and allowed to remain in the vagina 
about twenty-four hours. 

During this time the capillary bloodvessels will be depleted by the 
loss of a part of the serous portion of the blood they contain, and 
exosmosis from the intervascular spaces will also be excited in such 
a manner as to empty them of their contents. This leaves the part 
with which the glycerin comes in contact white, shrivelled, and les- 
sened in bulk, {. €., depleted. This is not all the good effect pro- 
duced by the glycerin applied to the cervix of the uterus, for the 
frequent removal of the serum from the intervascular sj^aces, which, 
of course, is replaced by a fresh supply from the vessels, is a very 
efficient means of dissolving out the fibrino-plastic material. It is, in 
fact, a kind of washing out of the tissue with serum derived from the mi- 
nute bloodvessels : it acts, therefore, both as a depletent and a solvent. 

Large hot-water injections constitute another valuable means of 
overcoming hyperaemia, and causing absorption of solid deposits. 

But there is another class of local remedies that I believe is more 
serviceable than these, and that is local stimulants applied db'ectly 
to the mucous membrane, such as iodine, carbolic acid, tincture of 
iron, acid nitrate of mercury, and many others that I might men- 
tion. In the teachings of twenty-five years ago the application of 
these remedies to the mucous memurane was supposed to exert only 
a very limited influence at the point to which they were applied, and 
we thought in applying nitrate of silver to an abraded or ulcerated 
surface the only effect it had was to heal up the abraded patch. Xow 
we know that this is a very small part of the effect of these local ap- 
plications. The vasomotor nerve supply of the whole uterus is so 
intimately connected that it may be considered a unit, and no j^art of 
it can be stimulated without affectingr the whole. Applications made 



HYPERINVOLUTION. 



441 



to the cervix of sufficient strength to stimulate its circulation to 
greater activity affiict every fibre and capillary in the organ in a sim- 
ilar manner. When, therefore, there is chronic engorgement of the 
uterus the very best way to get rid of it is to stimulate the circula- 
tion by local applications to the cervix. This same principle may be 
turned to great advantage by stimulating its internal mucous mem- 
brane, and one of the best ways to do this is to scrape the cavity of 
the uterus with a dull wire curette. 

This instrument may be introduced in most instances without dif- 
ficulty, and passed slowly but firmly over the whole surface. In 
some instances, where the mucous membrane is soft, small pieces may 
be brought out by the instrument, but generally this is not the case. 

When pieces of the mucous membrane are thus removed it would 
be too mechanical an explanation to say that the patient is cured be- 
cause the uterus has been partly or wholly divested of its diseased 
membrane. It is the excitomotor influence exerted on the nerves, 
and the consequent effect upon the whole circulation of the organ, that 
is the result of its use. 

It is not merely to the hsemorrhagic condition of subinvolution, 
but to the hypertrophic condition also, that the curette is applicable. 

Dilatation with compressed sponge has often accomplished good in 
the same kind of cases as those to which the curette is adapted, but 
it is a much more hazardous measure, and should only be resorted to 
when the other means fail. 



Hyperinvolution 

Is the state of the organ in which the involution has proceeded to 
such a degree as to condense the tissues beyond their ordinary density. 
The condensation thus accomplished renders it less vascular and erec- 
tile, and the fibrous structure is paler and harder than natural. As 
the result of this condensation and diminution in the quantity of the 
circulation, the uterus as a whole is smaller and lighter than common. 
The degree to which hyperinvolution may be carried varies greatly ; 
sometimes it is so slight as to require great care to distinguish it, at 
another the uterus is reduced to half its ordinary weight and dimensions. 

Causes. 

Inflammation seems here to be more concerned in the production 
of hyperinvolution than any other morbid process. From examina- 
tions during the progressive steps of morbid states of involution, I 
am inclined to think that in cases where inflammation of the mucous 



442 SUBINVOLUTION OF THE UTERUS. 

structures exists exclusiveljj or where inflammation of the raucous 
membrane preponderates, the involution is arrested, and hence we have 
subinvolution ; but when the inflammation is mostly confined to the 
submucous tissue it proceeds to hyperinvolution. 

Symptoyns. 

The condensation of the tissue and reduction of the vascularity of 
the organ always diminish the menstrual flow ; and hence we have de- 
creased menstruation in a moderate degree, and obstinate amenorrhoea 
in the more extreme condition. The symptoms attendant upon hyper- 
involution are very similar to those enumerated in the description of 
chronic inflammation. They are sometimes very distressing, rendering 
the patient thoroughly miserable for many years. The worst cases of 
this form of diseased involution I have met with have been traced to 
inflammation resulting from abortions; but it likewise takes place 
as the effect of inflammation after ordinary or full term parturition. 

Diagnosis. 

The diagnosis is easy with the aid of the uterine sound. This in- 
strument will not enter the uterus as far as it does into a healthy 
organ. The uterus is lighter and more easily moved, also, by the 
finger introduced into the vagina. 

One of the almost invariable effects of hyperinvolution is sterility. 
I have met with a number of cases of sterility occurring soon after 
marriage, on account of abortion, in the first three or four months, 
being followed by inflammation and hyperinvolution, the patient ever 
afterwards remaining sterile. 

The successful treatment of these cases requires a great deal of pa- 
tience and well-adapted measures. If the change in the condition of 
the uterus is slight we may sometimes succeed by introducing a bougie 
of slippery elm bark, large enough to distend the cavity of the cervix 
as much as practicable, three or four days before the expected men- 
strual discharge. This seldom fails to increase the discharge, and if 
used perseveringly for several months will sometimes cure the case. 
The bougie should be cut out of the bark so as to be about an inch 
and three-quarters in length, for cases of moderate contraction, and 
secured by a thread before introducing it. It should be allowed to 
remain until the discharge begins, and then removed. If, however, 
it is of long standing, and the diminution in size very considerable, 
we will be under the necessity of using the stem-pessary recom- 
mended by Professor Simpson. It may be made of zinc and copper, 
in order to add the influence of galvanism. 




CHAPTER XXX. 

CANCER OF THE UTERUS. 

"Those growths may be termed cancerous which destroy the 
natural structure of all the tissues, which are constitutional from 
their very commencement, or become so in the natural process of 
their development, and which, when once they have infected the 
constitution, if extirpated, invariably return, and conduct the person 
who is affected by them to inevitable destruction/^ (Miller, as quoted 
by West.) 

This general definition of cancer will include all its varieties, which 
are usually divided into four: 1st, medullary; 2d]y, epithelial; 
3dly, colloid ; 4thly, scirrhus. I have mentioned these varieties in 
the order of frequency in which they usually occur in the uterine 
tissues. I have not seen either a case of colloid or scirrhus in the 
uterus. There can be little doubt, however, that both are met 
with. The medullary variety is by far the most common form with 
which this organ is aifected, the epithelial being also quite common. 
Cancer of the uterus is of very frequent occurrence, and the deaths 
from it, compared to death from the same disease occurring elsewhere 
in women, predominate over all other localities. It attacks the cer- 
vical portion of the uterus more frequently than all other parts of 
the organ, yet it begins in every other portion, — in the fundus, body, 
or cavities of the body or cervix. In some rare instances it runs its 
course to fatal results without involving all these parts. When it 
begins in the cervix, it usually, either gradually or suddenly, passes 
upward to the fundus ; or if beginning in the fundus or body, it 
creeps downward to the os tincse. I have seen two instances where 
the lower portion of the cervix was but slightly, if at all, changed, 
while all the other parts of the organ were infiltrated by cancerous 
deposit. The material of cancer, particularly the medullary, is de- 
posited in the tissues, supplanting them more or less perfectly. 

The tissue most commonly attacked by all the varieties except the 
epithelial is the connective tissue. The parts attacked are thickened 
and indurated, the thickening and induration being very irregular in 
shape and size. If one of the lips of the os uteri is hardened from 
cancerous deposit, the elevated points are sharp and angular, and the 



444 CANCER OF THE UTERUS. 

hardened parts terminate abrujuly. and in a manner unlike the in- 
duration from auv other cau.-e. The hardening froo3 inflammatory 
fibrinous de230sit is more globular than angular, and less abrupt in 
its termination in the sound parts. If the cancerous deposit is in the 
body or side, on any part of the wall, it is enlarged into an irregular 
shape, and there are pits and points in many places. 

The infiltration and induration increases for an uncertain length 
of time, until, perhaps, the cancerous deposit so far displaces and re- 
places the ordinary tissues that the nutrition of the parts is disturbed 
by the destruction of the bloodvessels, and sloughing takes place over 
a small or large space, but always over an irregular space, thus leav- 
ing a greater or less chasm. This is ulceration, — cancerous ulcera- 
tion. The absorbents do not remove the parts, and thus- cause 
ulceration, but there is sloughing and denudation by death of many 
minute parts, the absorbents having but little to do in the process. 
The sloughing causes the smell and putrilaginous character of the 
discharges. This process "widens and deepens the chasm, sometimes 
quite rapidly, at others very slowly. In the case of the medullary 
variety, after induration and enlargement have advanced to a con- 
siderable extent in the uterus, the nutrition of the neighborinQ: organs 
and tis^ues is disturbed, and the deposit is infiltrated into all the sur- 
rounding parts, — the bladder, the rectum, the areolar tissue by the 
side of the uterus, the peritoneum, in fact, into everything in the 
neighborhood. This general deposit is not limited by the coverings 
or divisions of the parts, but all become united, so that all the 
pelvic tissues become one agglomerated mass of cancer ; or, if it take 
one direction more than another, the bladder and uterus may be glued 
together, or the rectum may be bound thus to the uterus. This dis- 
position of the deposit very soon becomes sufficient to fix the uterus 
immovably in its place. 

After the ulcerative process has fairly begun, it advances more or 
less rapidly, until much of the surrounding parts is destroyed; the 
bladder and uterus become one continttous cavity, and sooner or later 
the rectum also is laid open, and then the pelvic viscera are involved 
in one confused excavation, from which the putrilage of cancerous 
degeneration is poured out, commingled with urine, faeces, and 
blood. 

There is quite a constant proportion between the rapidity of the 
destructive progress of cancer and the age of the patient. It is slower 
in the aged, and destroys the young patient most readily. Of three 
cases under observation, in which cancerous deposit began in the body 



SYMPTOMS. 445 

or fundus of the uterus instead of the neck, two were in patients be- 
yond the climacteric period, one being sixty-four years of age and the 
other fifty-sev^en when the symptoms first attracted their attention. 
The other patient was forty-three. In this last patient, simultane- 
ously with the evidence of deposit in the body of the uterus signs of 
it appeared in the bladder, vagina, and clitoris, the duodenum, and 
in the pyloric orifice of the stomach. I always look for a more rapid 
degeneration of the tissues invaded by cancer in comparatively young 
patients. 

Symptoms, 

Discharges, pain, and fetor are the symptoms that usually attract 
our attention in cases of cancer of the uterus. When a patient com- 
plains of any of these, however, the case is generally an advanced 
one. Pain, perhaps, is the symptom first experienced, and is caused 
earlier than any other. Unfortunately, pain is so common to women 
— they suifer so often in the regions of the uterus and hips — that this 
symptom is not heeded by them until some other symptom makes its 
appearance. The pain is not generally intense nor troublesome until 
after the disease is recognized. ]N^or is it peculiar. It is described 
as lancinating, darting, twinging, — and very correctly, too, — but there 
is often nothing of this kind of pain during the whole course of 
uterine cancer. 

The discharges in cancer are of three kinds, and the mixture of 
them in different proportions. They are: 1st, blood; 2d, limpid 
serum; 3d, sloughs, generally minute. The first two are not offen- 
sive to the smell Avhen pure or mixed together, as they often are, and 
they only become so by being mingled with the last, by dissolving or 
holding in suspension or being merely mixed with greater or less 
pieces of dead tissue. In the earlier stages of cancer blood or 
serum may be, and generally is, effused, while the latter is reserved 
to the open or ulcerated stage. In this open or ulcerated stage all 
three kinds of discharges are almost always mixed together. In 
women who are still menstruating, the discharge first experienced is 
of blood. There is, at first, an increase in the amount of menstrual 
discharge; a little later, and blood is lost between the times of men- 
struation. The blood thus lost is derived from the same source as 
the menstrual blood, — the vessels of the mucous membrane of the 
corpus uteri. Later, when haemorrhage is so constant and attended 
with fetor, it is effused from eroded vessels upon the ulcerated sur- 
face. 

The blood in the former case is produced as the result of constant 



446 CANCER OF THE UTERUS. 

turgescence; in the latter, on account of the disintegration of tissue. 
Limpid, unoffensive serum is almost always observed in the cases of 
old women, after the menstrual period of life has passed, and gener- 
ally coming from the os uteri, which may be for a long time un- 
changed, indicating that it comes from some distance up in the organ. 
In fact, if the same serum was effused from the surface of the vaginal 
portion of the cervix it would most likely be mixed with blood, be- 
cause the parts producing it would not be sufficiently protected to 
insure the integrity of such frail tissue. In two remarkable instances 
the copious discharge of this limpid serum was, for many months, 
the only sign of disease presented by the patients. One of my pa- 
tients, sixty-one years old, had been under the necessity of wearing 
napkins for six or more months before calling my attention to her 
condition. The discharge was so copious when I saw her for the 
first time that I collected about two drachms from the speculum in 
ten minutes. When examined it was found to resemble distilled 
water in appearance, it was so clear and colorless. There was no 
smell nor other oflPensive quality to it. When examined by the mi- 
croscope no solid substances were found, except a very few natural 
epithelial scales. In a very gradual manner this transparent liquid 
became colored with blood. It was sometimes clear and sometimes 
bloody for several months before becoming fetid, and only for a few 
weeks before the patient died was it constantly bloody and fetid. 
The cervix uteri in this case was not attacked at all, and the mouth 
and lips of the neck were natural. The body of the uterus, as high 
as the fundus, was enlarged more than double its natural size, indu- 
rated, and nodulated; and, when examined after death, the walls pre- 
sented the peculiar friable hardness of medullary cancer, but there 
was no excrescence in the cavity, as I had expected to find. 

Whether the discharge is blood or serum at first, or a mixture of 
both, it is generally odorless ; but after a time it becomes fetid, and 
remains so persistently. The fetor appears, from the testimony of 
most observers, to be peculiar ; but I have not been able to dis- 
tinguish it from the smell of putrilage of other productions. When 
all these symptoms unite they form a case almost unmistakable. 
Lancinating pain, sero-sanguineous discharge, and peculiar fetor, 
continuing persistently, are almost distinctive of cancer. 

I cannot lay much stress on either one of these symptoms ; but of the 
three the most importance should be attached to the fetor. Persist- 
ing for weeks it should cause us to suspect a cancer. Contempo- 
raneous with the complete establishment of these symptoms we hav^e 



CAUSES. 447 

constitutional suffering. It is not often, I think, that general suffer- 
ing precedes the local symptoms of cancer, and it has always seemed 
to me to follow as the effect of local disease. It has not been my lot 
to meet with the broken-down constitution sometimes said "to be gen- 
erated by the cancerous diathesis. Cancerous angemia, causing the 
straw-colored translucency of the skin, considered characteristic of 
the malignant cachexia, is not distinguishable from the hsemorrhagic 
anaemia occurring sometimes in persons of the same age, produced by 
the drain upon the blood. 

In the fully developed condition of carcinoma the constitution 
suffers, and the collection of symptoms are such as arise from the 
embarrassment and failure of the functions in a long struggle with 
pain, loss of blood, anxiety, and inaction. Debility, with indigestion, 
palpitation, restlessness, neuralgia, constipation at first, colliquative 
diarrhoea and aphthae toward the end, nightsw^eats, wandering of 
mind, unsteadiness of purpose, succeeded by delirium and apathy; 
in fact, all the train of symptoms which precede dissolution when 
it approaches through protracted struggles, in which pain and ex- 
hausting discharges are the destroying agencies. 

Causes. 

But little can be said as to the causes of cancer of the uterus. The 
general opinion that it is hereditary in most cases is, doubtless, true ; 
and yet a great many instances occur that cannot be traced to such a 
cause. This is no reason why they may not be hereditary, because 
sometimes the circumstances which permit the hereditary taint to 
show itself do not exist for a number of generations. And, again, 
the taint may be so dilute as to require very favorable circumstances 
or co-operating causes to bring it out. If a mother dies of cancer at 
the age of forty-five, and impart the same morbid tendency to her 
daughters, the laws of cell- development would bring it about at the 
same age in the child. If, therefore, the daughter dies a year too 
soon of some other disease, the taint is inoperative, though present. 
Two or three generations of cancer-bearing persons cut off by other 
diseases lose the history of its inheritance. Or if a mother be the 
subject of cancer at the end of a life of active, nay, excessive, child- 
bearing, while her daughter leads a life of celibacy, or has but a 
single child, the physiological life of the two is so different that we 
would naturally expect some modification of consecutive cell-devel- 
opment to result. So that, although the hereditary taint is the same 
in the two, their jmthological ages may differ, and the daughter may 



448 CANCER OF THE UTERUS. 

not have cancer until a later period, and die before that time arrives. 
We should, I think, allow much for influences that may modify 
hereditary taints, and only regard them as hereditary tendencies, to 
be brought out in mother and daus^hter under similar circumstances, 
and which may be postponed or produced earlier in the one or the 
other by certain conditions. 

Married women are affected more frequently than the single, and 
the fruitful than the barren. When we consider how many more 
married than single women there are in civilized communities, and 
how few married women are sterile, we ought not to attach much 
importance to these facts. A much more significant fact is that a 
very large majority occur during the menstrual years of a woman's 
life. It is true that there may be nothing more than a mere coinci- 
dence in this fact, and that, after all, the hereditary mutations in the 
system during these years may bring about cancerous deposit, inde- 
pendently of any connection with the menstrual function. But it 
certainly is a coincidence, if not an etiological coincidence. As to 
the connection of cancer with chronic inflammation and ulceration of 
the uterus, much has been and may be said. I cannot lay my hand 
on statistics upon this subject, but I have never observed the coinci- 
dence of inflammation and cancer, or that cancer was a consequence 
of inflammation. If, however, they are occasionally connected, there 
are but few at the present day who believe cancer to be the result 
of long-continued inflammation. 

Diagnosis. 

It would seem that the diagnosis of a disease so marked as cancer 
would be an easy matter, and so it is when all or even most of the 
peculiarities of the disease have been fully developed ; but in the 
very beginning there may be much obscurity. A patient complain- 
ing of nothing more than a perfectly clear, inodorous, watery dis- 
charge, seemingly in the enjoyment of good health, would hardly be 
regarded as a victim to one of the most surely fatal and loathsome 
diseases incident to the human race ; and yet it is almost invariably 
so when the patient is advanced beyond the epoch allotted to men- 
struation. The cancerous disease, as it usually occurs, advances be- 
yond the period of doubtful symptoms in a very short time, and in 
the majority of cases our attendance is not requested until a scruti- 
nizing examination will enable us to decide very positively on the 
nature of the case. Our attention will be attracted by the unusual 
amount and character of discharge, pain, and smell. 



DIAGNOSIS. 449 

Summary of appearance in cases from Becquerel : 

" Cancerous Deposit. 

Cervix hard, unequal ; nodulated, os not always open, sometimes 
wrinkled or furrowed. 

Cancer of the neck often implicates the vagina. 

Hereditary influence is often traceable. 

Touch is painless. 

Discharge sometimes absent, in certain cases very abundant, and con- 
sisting, for the most part, of albuminous serum. 

Menstruation increased, being neither more nor less painful, and pass- 
ing often into the state of real hemorrhage. 

Absence of special anaemia when the vagina and body of the uterus 
are involved. Cancerous cachexia. 

Progress continuous and without cessation. 

The pain in cancer is very sharp, intense, and lancinating, and not 
influenced by locomotion or movements of any kind." 

^^ Ulcerated State. 

Developed at the critical period of life generally. 

Preceded and accompanied by haemorrhages. 

Severe, sharp, lancinating pain. 

Development essentially in sharp irregularities and nodosities. 

Adhesions to other organs soon as ulceration is formed ; immobility 
of the uterus. 

The surface only slightly soft, subjacent tissue scirrhous. 

Ulceration deep, unequal, essentially irregular, with thick, elevated, 
and hard edges. 

Always granulations. 

Discharges extremely abundant, consisting of purulent and often san- 
guineous serum ; nauseous and often fetid odor. 

Great haemorrhage from time to time, not necessarily at menstrual 
period." 

" Cancerous Ulceration 

Developed upon an hypertrophied and scirrhous surface. 

Ulceration deep, vast, unequal, grayish surface with thick edges, and 
easily bleeding. 

Ulcerated surface hard, presenting numerous lobes and tubercles, with 
nodosities and great hardness. 

Often great loss of substance. 

Cervix and corpus uteri immovable, on account of adhesions. 

Discharges sanious, fetid, sanguinolent, and of an insupportable and 
characteristic odor. 

Cancerous cachexia always present." 

29 



450 CANCER OF THE UTERUS. 



Prognosis, 

The prognosis of cancer is a gloomy one. Indeed, there is no dis- 
ease which so uniformly terminates fatally as cancer of the uterus. 
Notwithstanding this fact forces itself upon our observation, there will 
sometimes, in the course of a large experience, occur a recovery from 
it spontaneously and unexpectedly. I need not enter into the dis- 
cussion of the causes of this fatality. Whether the disease is essen- 
tially a blood-disease, or whether primarily local, there are but few 
instances in which it is not multilocular. It exists from the begin- 
ning, or very soon afterwards, in more than one place. Yet again, 
this is not invariably the case. We very seldom meet wdth an in- 
stance in which the area of deposit is small and confined to one 
locality. If this locality is accessible, the case possibly is curable. I 
say possibly, because the pathology is treacherous. This gloomy 
picture is in part relieved by the greatly improved palliative means 
we now possess. Very much may be done to allay the agonizing 
state of body and mind under its ravages. 

Treatment. 

Both medicinal and surgical means fail to give the profession 
much satisfaction in the treatment of cancer of the uterus. When 
the disease is clearly confined to the cervical portion of the organ, 
amputation of that portion holds out a very faint hope of cure. It 
is so common for the cells constituting the main bulk of the deposit 
to be scattered far beyond the apparent margin of the disease, that 
much more frequently than otherwise an abundant crop of them is 
left behind to continue the w^ork of destruction. Very rare instances 
of cure are reported. 

While, then, it is our duty to give our patient even a remote 
chance for recovery, we cannot hold out much hope of radical cure 
by removing the cervix. 

The same is true in reference to the operation for extirpating the 
entire uterus. The immediate danger attending the removal of the 
cervix need scarcely enter into our calculation of the benefits that 
may arise from it. This cannot be said, however, of the operation 
for exsecting the whole uterus. The dangers in this operation are 
manifold, and the results not far from fifty per cent, of deaths, while 
the immunity from a return is scarcely worth counting upon. 



TREATMENT. 451 

I do not think the operation can be sustained by success until the 
immediate dangers are very much diminished. 

For these operations see Epithelioma. 

Can we reasonably hope for a cure of cancer by medicine ? I 
think this question can be unqualifiedly answered in the negative. 

I fully believe that the rapidity of growth may sometimes be re- 
tarded, and possibly stayed for a, length of time. Many medicines 
have enjoyed the reputation of curing cancer, and have been used 
with implicit faith, but I may safely say that not one does at the 
present time. I need not stop to inquire how such reputation could 
have been acquired, except to say that until within a comparatively 
recent date other and curable diseases were mistaken for cancer. 
Quite lately we have been assured of the great powers of cundu- 
rango in this direction, and for a time there were very slight reasons 
to hope that it was a useful if not a curative means in the treatment 
of cancer. It has enjoyed a place in the category of cures for cancer 
for a shorter time than many others. 

Within a few months a beam of light has fallen upon the subject 
which has again awakened the hope that possibly we are on the eve 
of finding a medicine capable of influencing this destructive cell- 
growth. 

Professor John Clay,* obstetric surgeon to the Queen's Hospital, 
Birmingham, has had some very fortunate experience with Chian tur- 
pentine in uterine cancer. The statement, coming from one whose 
professional character, so far as I know, cannot be impeached, and 
published in the staid old journal, the London Lancet, must com- 
mand general attention. Considering our experience in the cure of 
cancer the results obtained by him seem marvellous, and for fear of 
marring the face of his report I abstain from making my own sum- 
mary, but will quote his case in full, together with some of his re- 
marks. 

"A woman came to the hospital as an out-patient, aged fifty-two. 
She was suffering from scirrhous cancer of the cervix and body of the 
uterus. Haemorrhage was excessive, pain of the back and abdomen 
agonizing, and cancerous cachexia well marked. The patient evidently 
had not a long time to live. The uterus was so extensively destroyed 
by the cancerous ulceration that its cavity readily admitted three fingers. 
In such a case it appeared to be justifiable to attempt to relieve the 

* June number, the report of London Lancet, 1880. 



452 CANCER OF THE UTERUS. 

snfferiDgs of the patient, even if the remedy should produce unfavorable 
symptoms, or should prove of no avail. I therefore prescribed Chiau 
turpentine, six grains; flowers of sulphur, four grains; to be made into 
two pills, to be taken every four hours. No opiates were prescribed or 
lotion used. No change was to be made in her diet or occupation. On 
the fourth day after taking the medicine the patient reported herself 
greatly relieved from pain, and was in better spirits, but she complained 
of a large amount of discharge. It w^as feared that she referred to a 
discharge of a sanguineous nature. On examination, however, the va- 
gina was found to be filled with a dirty-white secretion, so tenacious as 
to be capable of being pulled out ropelike, and this although she had 
syringed herself three hours previously. The os was quite contracted 
and would now scarcely admit the finger, and the surrounding swelling 
or cancerous infiltration of the cervix was much reduced. On the twelfth 
day the thick tenacious secretion had almost disappeared, and was suc- 
ceeded by a somewhat copious serous fluid. The os was not so firmly 
contracted, but would only admit the finger. The patient's general 
health was improved and the medicine well tolerated. Sixth week : I 
ordered her a quinine mixture in conjunction with the turpentine, but 
sickness supervened, which ceased on omitting the quinine. Twelfth 
week : My notes are, — the parts feel ragged and uneven, and do not bleed 
on roughly touching them. The speculum shows several cicatricial spots. 
The turpentine has been taken regularly during the day for twelve weeks 
every four hours, during which time she has been almost free from pain 
and has had no hseraorrhage ; no glandular enlargement ; general health 
improved. Walks easily to the hospital, being about a mile distant. 
As the patient did not come again to the hospital her address was ob- 
tained, and it was ascertained that she had left her residence. Being a 
widow she could not afl^ord to keep her home, and she went to reside 
with her married daughter in a northern town, but left no address. The 
case showed that the medicine was one of great power in cancer of the 
uterus, and it is to be regretted that an opportunity was not offered for 
fully carrying out the treatment. 

"Another patient, aged thirty-one, suflTering from cancer of the os and 
cervix uteri, was treated concurrently w^ith the one just mentioned. 
These parts were enlarged from carcinoma to the size of a hen's egg. 
The OS was dilated, and the cavity of the cervix was filled with epithe- 
lial growths, which bled freely on examination. Sacral pain was very 
severe, and haemorrhage had been continuous for the previous six weeks. 
The Chian turpentine and sulphur were given as in the previous case. 
The patient again attended at the hospital on the seventh day after tak- 
ing the medicine. She was in excellent spirits, and expressed her grati- 
tude for the relief aff*orded her. The medicine entirely relieved her 



4 



TREATMENT. 453 

paiu. She had increased white discharge. On examination the os and 
cervix were found to be nearly of the normal size. The os was patulous, 
and its surface was studded with flabby shotlike eminences, which did 
not bleed on roirghly rubbing them. I said to her: 'You are better; 
you must continue the medicine.' She answered: * I should think I 
must, for I could not do without the pills ;' they have eased me so very 
much.' She continued to improve, and on the fourth week she expressed 
herself as quite well. I impressed upon her the necessity of cou tinning 
the medicine, and told her to see me occasionally. She did not come to 
the hospital again for four months, when she brought another patient to 
consult me, believing that she was suffering from cancer. I reproved 
her for leaving off attendance at the hospital. She answered that she 
thought it unnecessary, as she had continued quite well. On this visit 
she submitted to an examination. The os was rough and irregular, but 
was of nearly the normal size ; no signs of cancerous infiltration ; the 
periods were regular, and not profuse, and were unattended with pain ; 
there was slight leucorrhoea. This case was a most remarkable one. 
The turpentine acted upon the growth with great vigor, literally melting 
it away in the brief period of four or five weeks. 

"The third case was one of epithelial cancer of the os, cervix, and the 
body of the uterus, in a woman, aged fifty-two years. The vagina was 
not involved. The mass was larger than a cricket-ball, almost filling the 
vagina. The border of the os was three-quarters of an inch in thickness, 
forming a ring of two and a half inches in diameter, through which pro- 
truded an epithelial growth, principally proceeding from the anterior 
wall of the uterus, and projecting about two and a half inches into the 
vagina. The case was sent to the hospital for my opinion by my son, 
Mr. Langsford Clay, who had attended the patient but a short time. 
The journey to the hospital fatigued her very much, and she declared 
that she could not come again, and that she did not wish to remain as 
an in-patient, believing that she could not live many days. She had re- 
peated haemorrhages, had much pain, and had the cancerous cachexia 
well pronounced. My son volunteered to attend her at home, and I 
agreed to see her occasionally with him. I thought it advisable, as an 
experiment, to vary the treatment somewhat, and ordered to be added to 
the pills one-sixth of a grain of the ammoniated copper, as from the 
large mass to be acted upon I thought that an astringent should be super- 
added to the turpentine. The dirty-white, tenacious discharge, appeared 
and continued for the first five weeks, but there was no haemorrhage after 
the first examination. The swollen os uteri and the cervix beyond were 
the first to show signs of diminution ; this was noted on the fourteenth 
day. The tumor, however, was rough and shrunken, and did not project 
so much. Sixth week: The surface of the tumor was at the level of the 



454 CANCER OF THE UTERUS. 

OS uteri, and seemed to consist of a mass of bloodvessels, which bled 
moderately after examination. This condition occasioned me some sur- 
prise, as three weeks previously the patient was ordered a lotion made 
with perchloride of iron, with a view to arrest haemorrhage, since from 
her anaemic condition it was feared that the loss of a moderate amount 
of blood would be followed by serious consequences. I asked her what 
kind of a syringe she used with the lotion? She replied, 'I thought 
the lotion was merely to bathe the external parts.' This, as it happened, 
was very satisfactory information, as it showed that the lotion had no 
share in the reduction of the mass, which now was scarcely half the 
original size. She was supplied with a syringe for the purpose of apply- 
ing the lotion, and after using it three days the mass of vessels had con- 
siderably shrunken, and no longer bled on manipulation ; but the surface 
of the growth had the touch and appearance of a gangrenous mass, but 
there was scarcely any fetor. The patient now complained of gastro- 
dynia, with colicky pains in the bowels, but she had no diarrhoea or 
vomiting. I believed this to be due to the copper, and it was con- 
sequently discontinued. It also appeared to me that the turpentine 
might not be efficiently digested in the solid form, and that it would 
be better if the remedy were administered in a state of minute subdi- 
vision, as in the form of an emulsion. An ethereal solution of Chian 
turpentine was prepared by dissolving one ounce of the turpentine in 
two ounces of pure sulphuric ether (anaesthetic). The ether dissolved 
the turpentine instantly. This solution was given to our skilful dis- 
penser, Mr. Whinfield, with a request that he would prepare a pleasant 
mixture or emulsion from it; and, after a few trials, he prepared one 
which is not unpleasant to take, according to the following formula : 
Solution of Chian turpentine, half an ounce ; solution of tragacanth, four 
ounces; syrup, one ounce; flowers of sulphur, forty grains ; water to 
sixteen ounces ; one ounce three times daily. This form of mixture was 
given to the patient, and was much liked. She has now taken the turpen- 
tine for thirteen weeks uninterruptedly. The os uteri is a little more than 
one inch in diameter, and feels like a ring of cartilage about a quarter 
of an inch in thickness. The tumor has nearly disappeared, and the 
finger can be introduced posteriorly into the uterus for more than an 
inch. The general health has much improved, and she is quite free from 
pain and looks cheerful, and is becoming stouter. No sedative whatever 
has been given during the treatment. Fourteenth week : She complained 
of severe ' cramplike pains' in the back and lower part of the abdomen, 
which she attributed to the mixture, and in consequence it was discon- 
tinued for a few days, and an opiate given, by which she was greatly 
relieved. The turpentine was again resumed. Nineteenth week : She 
is now fairly convalescent. The growth has almost disappeared, and the 



TREATMENT. 455 

parts beyond the os uteri are somewhat hypertrophied, yet are almost 
normal to the touch. 

" The fourth case was that of a patient aged thirty-two years, who 
came to the hospital after having been discharged as incurable from the 
Women's Hospital. She was greatly depressed, and was most desirous 
to be cured, for the sake of her family of young children. She has had 
repeated floodiugs, and suffered greatly from pain during the past five 
months. Constipation very troublesome, which probably arose from the 
opiates she had been in the habit of taking. On examination, she was 
found to be suffering from epithelial cancer of the os and cervix uteri, but 
not involving the vagina. There was a cancerous mass of the posterior parts 
of the OS and cervix, of the size of a goose-egg. This growth pushed the os 
uteri towards the pubis, almost preventing that part from being felt. The 
turpentine mixture was given her three times daily, and from this period 
a very rapid diminution of the growth took place, so that by the six- 
teenth day it had almost entirely disappeared. The os uteri was now 
in situ, admitting the finger readily, and there was the same condition 
of the vessels as that observed in the preceding case. The lotion with 
the perchloride of iron was used daily for a few days with excellent 
effect. In the ninth week the patient suffered from spasmodic pains in 
the back and abdomen, and as this was attributed to the medicine, it 
was discontinued, and iodide of calcium, in five-grain doses, three times 
daily, was administered. This was taken for about a fortnight, but, not 
feeling so well, the patient was admitted into the hospital. The condi- 
tion of the internal organs was now much the same as before, the iodide 
of calcium was given, but there was some thickening about the cervix, 
which was fixed to the vagina. The rectum was excessively loaded, and 
required several days to effectually relieve it. The Chian turpentine was 
administered simply ; but a lotion was prescribed, containing six grains of 
white arsenic to one pint of water, to be used daily. Under this treatment 
the women very rapidly improved, the pains entirely ceased, and the parts 
became much reduced in size, and more movable. The patient was now 
anxious to leave the hospital for her home, as she felt quite well ; but it 
was deemed advisable to send her to the Sanatorium instead. She is very 
active, cheerful, and happy, and may be pronounced convalescent. 

" Other cases are under treatment, both in the hospital and privately, 
all showing similar effects. The remedy is now being tried in cancer of 
other organs, and apparently with good results. One of the most in- 
teresting, perhaps, is a case of scirrhus of the breast, which has been under 
observation for some weeks. Among the other cases are cancer of the 
vulva, stomach, and abdomen, in which very remarkable benefit has been 
already produced. 

"From the results obtained by the use of Chian turpentine, it may be 
confidently said that the remedy does exert a powerful action on 



456 CANCER OF THE UTERUS. 

cancer of the female generative organs in particular, and it will be of 
advantage to point out some of the conclusions at which I have arrived 
respecting the efficacy of the drug, and the manner in which it should 
be employed. The oil of turpentine, if it produces any effect on cancer, 
is inadmissible on account of the speedy production of its specific effects 
even when administered in small doses. The same remark applies with 
less force to the Venice and Strasbourg turpentines ; in my hands they 
have not produced the same beneficial effects on cancerous growths as 
the Chian turpentine has done. The maximum dose of the last-named 
drug which can be safely and continuously given is twenty-five grains 
daily. It is advisable to discontinue the remedy for a few days after 
ten or twelve weeks' constant administration, and then to resume it as 
before. The combination with sulphur was given at first, and has been 
continued. It is doubtful whether much benefit is derived from the 
combination, but the effects have been so uniformly good with it, that it 
was thought advisable to continue its use. There is every reason to be- 
lieve, from the trials made with other substances in combination with 
the turpentine, such as carbonate of lime, iodide of calcium, ammoniated 
copper, quinine, berberine, hydrastin, etc., that the turpentine is best 
administered simply, as the most marked and rapid effects have always 
been manifested when it has been given alone. 

" The turpentine appears to act upon the periphery of the growth with 
great vigor, causing the speedy disappearance of what is usually termed 
the cancerous infiltration, and thereby arresting the further development 
of the tumor. It produces equally efficient results on the whole mass, 
seemingly destroying its vitality, but more slowly. It appears to dis- 
solve all the cancer cells, leaving the vessels to become subsequently 
atrophied, and the firmer structures to gradually gain a comparatively 
normal condition. 

" It is a most efficient anodyne, causing an entire cessation of pain in 
a few days, and far more effectually than any sedative that I have ever 
given. In the cases I have described no sedative was employed in any 
instance, although in some cases where great pain had existed previously 
to commencing the treatment, large doses had been given. Whether 
this arrest of pain arises from the death of the tumor, or, as my son sug- 
gests, is due to there being no longer irritation of the sentient nerves (in 
consequence of tension being withdrawn by the removal of the cells), 
the fact is the same. 

" If, after the use of the remedy for some weeks, one of these cases 
were examined by a stranger for the first time, he would probably con- 
clude that it was one of commencing malignant disease, by reason of 
the irregularities of its surface. The effect of the remedy being first to 
remove the cellular structures, any loss of tissue produced by the inva- 
sion of the disease cannot be restored, and hence the irregular touch and 



TREATMENT. 457 

appearance even after cicatrization. The arrest of the h?emorrhagic dis- 
charge and the remarkable freedom from glandular affections, after a 
lengthened use of the turpentine, are especially important factors in 
materially aiding the removal of the cachexia, and of improving the 
general condition of the patient. 

" Without being in position to affirm that the Chian turpentine is a 
positive cure for advanced cancer of the female generative organs, yet, 
however, the facts here adduced may be interpreted in this respect, two 
circumstances are indisputable — one, that all the patients after several 
months' treatment are living, and that the disease has not advanced as 
is usually the case, but has retrogressed — in fact, has all but disap- 
peared ; and it may at least be safely asserted that when the remedy is 
steadily used for some time it arrests the progress of the disease, and re- 
lieves the pain incidental to the morbid growth in a manner which can- 
not be said of any other remedy. It is probable that on an extended 
experience of its use and by variations of the mode of administration, it 
may prove an effectual cure for this intractable disorder. Patience and 
perseverance on the part of patient and medical adviser are absolutely 
required. AVe know that in some diseases, as bronchocele and syphilis, 
a long continuance of well-known remedies is often necessary to affect a 
cure of the particular disorder, and that the administration of the 
remedies has to be varied from time to time, according to the thera- 
peutic effects produced by the drugs. In cancer, as far as experience 
has at present indicated, the same alternating method may perhaps have 
to be employed. Whatever may be the ultimate results there can be 
no doubt that Chian turpentine in these disorders is a most valuable 
medicine. Judging by my experience it is no figurative expression to 
say that it acts as a direct poison upon the growth, probably causing its 
ultimate death. In advanced cancer the process of reparation is slow, 
but if the surrounding structures are not too much involved in the pro- 
cess of destruction, it will seem that a cure may be reasonably expected. 
It is not that the remedy has failed against the cancer, but that the 
vital organs are so much destroyed that their complete reconstruction 
and adjustment of functions are not possible, and life fails in conse- 
quence of their mutilated condition. Even under these circumstances, 
if the cancer does not recur, the efficacy of the medicine is obvious. In 
the early stages of cancer it may be affirmed that an undoubted cure 
may take place speedily, and as the contiguous structures are not ex- 
tensively involved, but little deformity ensues; and experience justifies 
the expectation that under such circumstances a recurrence of the dis- 
ease will not follow. 

" The history of the local treatment of cancer of the uterus is one of 
singular interest, and is highly instructive to the practical physician. 
The contrast between the general and local treatment is the more notable, 



458 CANCER OF THE UTERUS. 

as Dothing can be more injurious to the welfare of the patient than an 
attempt to destroy the cancer by external agencies. The disease is not 
to be averted by this means, as the symptoms assume a more intense and 
threatening character, until the patient rapidly sinks. It may be ob- 
served that the internal treatment here recommended when used for a 
considerable period is borne by the patient with remarkable tolerance. 
As I have mentioned, in some of my experiments I determined, in order 
most thoroughly to test the medicine, to reply upon this alone. Recently 
the arsenical lotion has been superadded, and with no injurious conse- 
quences — it appears to act as a disinfectant, and it may produce some 
benefit by promoting the cicatrization of the tissues. Several sugges- 
tions offer themselves for inquiry as to aiding locally the detachment of 
the growth, after its vitality has been destroyed ; but this is not of much 
importance, as there seems to be no fear of the blood becoming affected 
by the absorption of the decaying tissues, the turpentine probably pre- 
venting any such calamitous occurrence. 

"If the practice now described should prove by future experience to 
be justified, then it will be incumbent upon the medical adviser to treat 
cancer of the generative organs at an early stage of its development, and 
it is reasonable to conclude that this dreaded and most fatal disease will 
no longer be the scourge it has hitherto proved, and that another benefit 
will have been conferred upon suflfering humanity by the resources of 
therapeutic art." 

Palliation. 

There comes a time in the progress of cancer of the uterus that the 
patient is prostrated by the septic effects, caused by absorption of gan- 
grenous products at the surface of the degenerating mass. When this 
is the case we may often relieve the patient more by removing all the 
dead and dying tissue with a sharp curette and thermo-cautery than 
any other way. To do this the vagina should be dilated with Sims's 
or Simon's speculum until the parts are thoroughly exposed. Then 
with the sharp curette we should gouge out and remove in detail 
all the diseased substance down to the solid tissue of the cervix, and 
then cauterize the whole surface with the thermo-cautery. In this 
way, for a time, get rid of the haemorrhage, the fetid discharge, and 
often the distressing pain. . 

After this the patient's general health will almost always be 
greatly improved, and she a happy respite from her terrible suffer- 
ing. 

This operation may be repeated once or oftener, as the conditions 
seem to justify. 

One who has never tried this method of relieving the patient would 



PALLIATION. 459 

very naturally be deterred from resorting to it by fear that the haem- 
orrhage would be dangerously profuse. A trial, however, will prove 
to him that this apprehension is groundless. If the curetting part 
of the operation is done briskly there will not generally be much 
hsemorrhaw, and the benefits resultino^ from it will far exceed the ill 
effects of the loss thus incurred. 

I mention this as the first and most important palliative measure 
to which we can resort, as the comfort of the patient will be promoted 
to a greater extent than by a resort to any other measure. 

Palliation of the pain, smell, and debility, is the object of the most 
of our treatment. We use local remedies for pain, introduced into 
the vagina. Of course, the anodyne and anaesthetic remedial agents 
constitute our resources for combating pain. Opium, belladonna, cicuta, 
hyoscyamus, and Indian hemp, may all be used locally for the pain. 
The best form for their application locally, is that of a bolus of five 
grains of pul. opii. We may instruct the patient to introduce the finely 
powdered opium through a small glass tube, with a piston of whalebone 
and cotton. It is applied thus to the ulcerated part and walls of the 
vagina in the neighborhood, and very effectually acts as an anodyne. 
Ten grains of the extract of hyoscyamus may be used as a bolus, or 
two grains of ext. belladonna ; and so on with all the anodynes. A 
grain of morphia may be mixed with the ext. hyos. to great advan- 
tage. 

Medicated injections often soothe the diseased part very much also. 
The watery extract of opium may be thrown into the vagina by a 
small syringe, and allowed to remain, the patient lying on her back 
for a length of time. Hydrocyanic acid in solution, gtt. xx to a pint 
of water, passed through the vagina, has a very pleasant effect some- 
times. Injections of vapors of the ansesthetics are highly recom- 
mended, particularly by Professor Simpson. Carbonic acid gas and 
chloroform are those most used. 

The chloroform vapor may be passed through the vagina by the 
ordinary perpetual syringe, made by the Union Rubber Company. 
The chloroform should be placed in the bottom of a large bottle, 
while the receiving-tube of the syringe may be passed through the 
cork and made air-tight with wax. The other end, being inserted 
in the vagina, high enough to almost come in contact with the dis- 
ease, the pumping may be commenced. The vapor will be caused to 
rise in the bottle quite rapidly under the exhausting influence of the 
syringe. Care should be taken not to let the tube deep enough in 
the bottle to come in contact with the chloroform, lest this fluid, in- 



460 CANCER OF THE UTERUS. 

stead of its vapor, pass through the instrument. The vapor thus 
delivered into the vagina causes a sense of heat and glow, which very 
soon seems to replace the pain. When properly done, patients expe- 
rience great relief from this gaseous injection. The same apparatus 
will do to convey carbonic acid gas to the parts. The gas is gener- 
ated by mixing in the bottle carb. soda and tart, acid, and then pour- 
ing a little water upon it. Although I have never yet tried the effect 
of great cold to the part, I have no doubt it would be very effective 
in relieving the pain. It should be applied through the speculum 
directly to the parts diseased, and no other. A small amount of the 
freezing mixture, of two parts pounded ice and one part common 
salt, in a small muslin bag, is the means used by Professor Simpson. 
It is thought this cold not only relieves the pain, but that it retards 
the advance of the disease somewhat. The contact should be con- 
tinued until the parts assume a pale, bloodless appearance, when this 
is practicable, and may be used twice or three times in twenty-four 
hours. With the local remedies for pain maybe mentioned the sub- 
cutaneous injection of morphia over the sacrum, or in the iliac region. 

All local remedies for pain will, after awhile, fall short of the 
relief demanded by our suffering patients, and we will be under the 
necessity of introducing them into the system in a jnore effective 
manner. We must resort to their internal use. I need not mention 
the anodynes to which we would resort in such cases ; they are well 
known to the profession. I would, however, caution the student not 
to use opium when any of the others will answer the purpose. Indian 
hemp will be found to do this more frequently than any of the others. 
They will all fail, eventually, and opium will prove the great bless- 
ing in such cases. And let me add the further caution : to commence 
Avith as small doses as will answer the purpose; and while we deal 
liberally enough wath the drug to get its good effects, increase it slowly 
as possible, for with all our precautions in this respect we will be 
under the necessity of giving it enormously. The anaesthetics are 
too evanescent to be relied upon for main remedies, but they will 
render the influence of opium more prompt, and perhaps lasting. 

The haemorrhage of cancer will sometimes require prompt inter- 
ference. I think, however, that although the bleeding is always ulti- 
mately exhausting, that it is seldom immediately dangerous from its 
copiousness. I have generally, when the haemorrhage required in- 
terference, depended upon the introduction of small pieces of ice fre- 
quently repeated. It is often very grateful to the patient as well as 
haemostatic. Dr. Simpson recommends powdered tannin introduced 



PALLIATION. 461 

through the speculum and placed on the part; but he places more 
dependence on a paste made of perchloride of iron and glycerin. If 
the bleeding should be very alarming, notwithstanding these means, 
the tampon would be our last resort. 

The offensive odor emanating from the disease makes it very de- 
sirable to have some means of correcting it. I should remark, witli 
reference to the plans often resorted to, that they are more or less 
injurious to the patient and attendant, viz., the burning of sugar, 
myrrh, etc., in the room. This should be done very sparingly. For 
the air, chloride of lime and good ventilation will do better than all 
other expedients. We do not wish to make a stronger smell less 
offensive, to be sure, but we desire to remove the effluvia. Burnt 
sugar simply fills the room with various other less offensive gases, 
which we breathe with them, the original cause of the trouble. 
Chlorine, disengaged from the chloride of lime, probably destroys 
the material floating in the air that offends the sense of smell. But 
the emanation may be lessened by the use of carbolized water as a 
w^ash and injection. Frequent changes of the linen and bedding of 
the patient are matters of cleanliness that, of course, will readily sug- 
gest themselves. 

Septicaemia is the condition which most commonly causes the great- 
est suffering and hurries the patient towards a fatal issue. Any pal- 
liative measure, therefore, which enables us to stay or modify its 
course, will prove a source of great relief. The absorption of the 
liquid products of the necrosed and sloughing tissue eliminated from 
the surface of the ulcer is the cause of the septic fever; hence a most 
important item in the palliative treatment of cancer is to keep the 
surface of the ulcer as free from dead and fungous substance as pos- 
sible. This may, and ought to, be done by removing it with the 
sharp curette as often as necessary. When we operate for the re- 
moval of the necrosed substance and fungus, the parts should be well 
exposed by Sims's or Simon's retractor speculum, the vagina thor- 
oughly washed out, and then freely sponged with the tincture of iron. 
This will enable us to see the line of demarcation between the sound 
and dead tissue. Then with Simon\s spoon every portion of the rot- 
ten substance should be freely removed. During the operation fre- 
quent washing away of the blood will be necessary, that we may see 
what we are doing. When the ulceration is extensive, and making 
its way toward the bladder or posterior peritoneal cul-de-sac, it will 
require care to avoid opening one of these cavities. 

Although I have done this palliative operation a great many times, 



462 



CANCER OF THE UTERUS. 



I have not seen an excessive loss of blood or any other serious eon- 
sequence follow it. It is always better, however, to be prepared with 

Fig. ISo. Fig. 136. 




P 



Sharp Curette, Sietnond's C^ixette. 

means by which to check the bleeding, and probably the best is tne 
thermo'cautery. If this, or some other form of cautery, cannot be 



PALLIATION. 463 

commended, and haemorrhage is sufficient to require an haemostatic, 
a tampon of cotton, saturated with a solution of the persulphate of 
iron, may be advantageously used. 

It is surprising how much relief this little operation generally 
aifords. The patient will often be so much improved as to indulge 
in the hope that she is recovering from her loathsome disease. In a 
greater or less time, however, the symptoms will return, and may be 
again relieved by the operation. 

When a case is advancing slowly, this process of cleansing the ulcer 
may be profitably and safely resorted to a number of times. We 
ought not to try to remove any of the tissue beneath the ulcerated 
surface, but confine the operation to the scraping away of the necrosed 
substance. This same operation is applicable to cases in which there 
are frequent haemorrhagic discharges. It generally puts a check, and 
sometimes permanently, to losses of this kind, especially if followed 
by the use of the actual cautery or the ther mo-cautery. The history 
of this terrible malady discloses many disappointments in discoveries 
of cancer cures. The more recent discoveries of this kind are the 
jaborandi and Chian turpentine. The former temporarily tempted 
the credence of the more sanguine of the profession, but after repeated 
trials has been condemned as utterly w^orthless. 

The Chian turpentine, which, on account of the great respectability 
of its early advocate, seemed to hold out a faint hope that we were 
on the threshold of a valuable discovery, has been found wanting 
also. That the progress of cancerous deposit will ever be arrested 
by medicine is a problem for the future. That true cancer of the 
uterus can be cured by any kind of surgical operation is yet to be 
proven. Cancerous deposit in the uterus, if not the result of blood 
disease, is a focus from which widespread contamination emanates in 
every direction, to an extent that surgery cannot reach. 

Such is the melancholy paucity of our resources in cancer of the 
uterus. Scarce as they are, however, they may afford the suiferer 
great comfort ; and we should fall short of our duty if we did not 
industriously employ them, as the best the profession can afford. 



CHAPTEE XXXI. 

EPITHELIOMA, CANCEOID, EPITHELIAL CANCEE OF THE UTEEUS. 

All these terms, with many others, are applied to a fungoid de- 
velopment in and upon the mucous membrane of the uterus. It is 
essentially an excessive and modified proliferation of the epithelial 
cells, which destroys the membrane upon which it grows, and slowly 
penetrates adjoining structures. 

Its development is not by interstitial deposit, as in other varieties 
of cancer, but consists of superficial accumulations and soft deposits 
of epithelial cells, held together by very delicate, connective tissue. 

Fig. 137. 




The shape of the deposit, or growth, varies. In some instances it 
is thinly spread over a large surface, while in others it grows out as 
a fungus from a restricted area. In the former instance the whole 
mucous membrane of the cavity of the uterus may be overlaid and 
permeated by it, from the external orifice to the fundus, and thus be 



EPITHELIOMA 



CANCROID. 



465 



converted into a flat, friable covering of the deeper structure ; while 
in the latter there may be fungi, of greater or less size, projecting 
from the mUcous membrane of the uterine cavity ; but much more 
frequently they spring from one of the cervical labia, or the whole 
cervical circle. 

The substance of the membrane thus diseased is generally hyper- 
trophied, but not otherwise very much changed in character, until 

Fig. 138. 




the disease has made great progress on the membrane itself When 
the disease is situated in the endometrium the body of the uterus may 
be enlarged for a long time, and never attached to the other organs. 
When the growth occupies the external membrane of one of the 
cervical labia the submucous structure is sometimes increased so that 
it may project into the vagina much beyond its ordinary extent. This 
will give the appearance of a large fungus, while it is really the 
hypertrophied lip covered with cancroid deposit. At other times 
the labium is not so much enlarged, while the fungus projects down 
sufficiently to partially or wholly fill the vagina. 

In all of these varieties, after a time, "the more superficial parts of 

30 



466 



EPITHELIAL CANCER OF THE UTERUS. 



the growth undergoes a process of necrosis and sloughs off. The par- 
ticles thus sphacelated, together with sanguineous and mucous fluids, 
constitute the discharges from epitheliomatous surfaces. 

Disintegration of this sort is generally accompanied with further 
growth, so that the size of the deposit is not materially, if at all, 
diminished. 

Fig. 139. 




Fungus Growing from the Cervix. 

When the process of disintegration has fairly begun the symptoms 
of cancer become developed, and gradually the role of septic symp- 
toms supervenes, and carcinomatous dyscrasia is established. 

Diagnosis. 

The symptoms of epithelioma are the same as in other forms of 
cancer. They have already been described, and I need not reproduce 



DIAGNOSIS. 



467 



them here. AVe may differentiate epithelioma from other forms of 
cancer by examination with the finger and sound. In epithelioma 
there is an absence of the irreo^ular hardness caused by the submucous 
deposit by the presence of a soft, friable projection into the vagina, or 
the same kind of substance occupying the whole of the cervix, not 
indurated, but somewhat enlarged. When this substance exists in 
the mouth of the uterus we may ascertain how far it extends by 
passing the sound through it into the cavity. The resistance to the 
instrument will be slight, yet sufficient to impart that feeling of re- 
sistance caused by its passage through a yielding tissue. If the de- 
posit is confined to the cervix the slight opposition to the advance of 




Structure of Epithelioma. — From Cornil and Ranvier. 

the instrument will cease before it reaches the uterine cavity. If it 
extends to the fundus the resistance will continue the whole depth of 
the organ. 

I can imagine, although I have not met with such a case, that a 
polypus in a gangrenous condition might embarrass us somewhat ia 
making a diagnosis. The use of the microscope would clear up the 
difficulty in such a case. A very small piece pinched ofp from the 
mass will suffice for examination. In the disintegrated substance of 
the polypus we would find the debris of fibrous tissue, while the 
cells of epithelioma would be found in the malignant growth. If a 
sarcomatous polypus should occupy the vagina the microscopic test 
would be equally decisive. 

From a decaying placenta, arrested in the os uteri, we would dis- 
tinguish the epithelioma by means of the microscope, in case any 
doubt should arise. 



468 



EPITHELIAL CANCER OF THE UTERUS, 



Prognosis. 

The prognosis is not so hopeless as in the other varieties of cancer 
of the uterus, as it is usually localized — in the earlier stages at least 
it is occasionally amenable to treatment. Without treatment it is 
equally fatal, as the morbid process is progressive to an unlimited 
extent. 

Treatment, 

The treatment of epithelioma of the uterus, as just intimated, is 
much more promising than the other cancerous affections. The cura- 
tive treatment consists in removing the whole of the disease, and 
^yhen this is practicable we may reasonably indulge a hope of success. 

Fig. 141. 




Dr. Paquelin's Thenno-cauten-. 

This can generally be done when the morbid deposit is confined to 
the vaginal portion of the cervix, and sometimes when it extends to 
the fundus of the uterus. The means we possess by which this may 
be accomplished are the knife, the scissors, the ecraseur, — wire or 
chain, — the galvanocautery, and the thermo-cautery, or the actual 
cautery. 

I have performed the operation for removing epithelioma by all 
these different instruments separately, and by using several of them 
in the same operation. 



A 



TREATMENT. 



469 



Dr. John Byrne, of Brooklyn, in a very interesting article pub- 
lished in the second volume of the Transactions of the American 
Gynaecological Society, advocates the exclusive use of the galvano- 
cautery. He gives a number of cases illustrated by his method of 
operating, and of the success following it. The results are very en- 
couraging, and at the time his plan was published it was regarded as 
most promising. He exposed the cervix by his speculum, and ampu- 
tated it with his cautery knife, heated by the battery to a tem- 
perature that made it assume a dull red color; or, surrounding the 



Fig. 142. 



Fig. 143. 




Byrne's Cautery Battery. 



Byrne's Cautery Ecraseur. 



cervix, or that portion to be removed by the platinum wire, and then 
applying the battery so as to heat it to the same temperature. In 
doing the operation according to the latter method the cervix is fixed 
by the vulsellum, and, if movable, drawn down to a convenient dis- 
tance from the vulva, and the wire, while cold, placed around the 
cervix as high as possible not to include the utero- vaginal junction. 
In this position the wire is tightened while cold, and then heated. 



470 



EPITHELIAL CANCER OF THE UTERUS. 



Before heating the wire the constriction should be increased slowly 
until the wire has fairly imbedded itself into the included tissue. 

Quite forcible traction^ exerted by the vulsellum, should be main- 
tained while the wire is slowly passing through the substance of the 
neck. This will cause the central portion of the amputated cervix 
to be divided higher than the periphery, and the cavity will be 
conoid in shape with the apex in the centre. If the disease is not all 
removed by this operation the cautery knife may be applied, as dif- 

FlG. 144. 




rn 




Byrne's Cautery Electrodes. 

ferent parts are drawn down by hooks, until the operator is assured 
that all the disease is removed, or that the operation is carried as far 
as the integrity of the bladder and peritoneal cavity will allow. 

The prominent dangers in performing this operation are haemor- 
rhage, wounding the peritoneal cavity, and opening the bladder. The 
first may be avoided by having the temperature of the wire low. If 
it is white hot it will cut the tissues, including the arteries, without 
closing the latter. But if of a dull red heat it will coagulate the 
albumen in the areolar tissue, and the blood in the arteries, some dis- 
tance from the wire. In this way the vessels will be sealed and 
primary haemorrhage avoided. To avoid wounding the bladder or 



TREATMENT. 471 

peritoneum, I am in the habit of applying the wire with the cervix 
in its normal position, and making traction after the wire has been 
drawn tight enough to fix it firmly in its bed. If we are careful to 
apply the wire in this way, there is not much danger of accident. 
When the disease does not extend to the junction between the 
vagina and uterus, this is an admirable method of removing the 
cervix. The objections I make to the galvauo-cautery are, that it 
requires more skill in the management of the battery than most prac- 
titioners possess ; that the burnt surface is so changed we are unable 
to judge whether at the point of separation all of the disease has been 
removed or not; that it is cumbersome as a portable instrument, and 
that it is no better in any respect and not so manageable as the thermo- 
cautery. I think also that the great heat generated in the vagina is 
not without objection. The advantages are that it destroys the cell 
growth some distance above the surface of the amputated stump, and 
the operation is entirely bloodless. I have not employed it in my 
recent operations. 

In removing the cervix for epithelioma, it wnll be very convenient, 
however, to have the galvano-cautery, or the thermo-cautery, as one 
of the instruments, but if we intend to thoroughly remove the disease, 
and especially if it extends above the vagino-uterine juuction, I think 
we can remove it more safely with the scissors or knife, or both. 

If there is much of a tumor projecting into the vagina, I generally 
apply the ecraseur around it, and include, if possible, the whole of 
the vaginal neck within its grasp. I use the chain instead of the 
wire in the ecraseur because I find it much easier to manage. We 
should be very careful in the adjustment of the chain to avoid injur- 
ing the bladder or penetrating the peritoneal cavity. In this part 
of the operation the galvano-cautery may be used in place of the 
Ecraseur. If we use the ordinary ecraseur, there is no need of dilat- 
ing the vagina with any sort of speculum ; but if we use the hot wire, 
then the vagina should be well dilated by Sims's speculum, Simon's 
retractor, or Byrne's speculum. After as much as possible of the 
vaginal cervix has been removed in this way, the most important 
part of the operation is just begun, because, in most cases we will 
not be sure of having removed all the diseased tissue. The surface 
from which the neck has been thus removed should be examined 
thoroughly. We can do this best by seizing it with the vulsellum 
or single hooks and drawing it down as low as possible, where it can 
be thoroughly examined. It will also insure precision to examine 
the portion amputated from the cervix to ascertain whether any of 



472 EPITHELIAL CANCER OF THE UTERUS. 

the diseased tissue was cut through, or whether the cut surface is all 
sound or not. 

If we can assure ourselves in this way that the disease is all re- 
moved, we have little else to do than secure our patient from haem- 
orrhage. In my own operations I have had no trouble with any of 
the arteries divided. They usually spirt pretty freely for a few min- 
utes, and then gradually cease bleeding. I do not make this state- 
ment to encourage carelessness as to haemorrhage, because, in excep- 
tional instances, in the hands of other operators, there must have been 
dangerous cases. Hence, as a precaution against haemorrhage, and 
for the purpose of destroying the cell growth deeply, we should apply 
the cautery at a dull red heat all over the amputated surface. If we 
find by the examination of both amputated surfaces that we have not 
removed all of the disease, or if we have any doubt upon the subject, 
we should seize point after point of the remaining portion of the 
uterus and cut it off with the scissors, and thus excavate the supra- 
vaginal cervix and body of the uterus as high as practicable, or until 
we are satisfied that all the disease is removed. By the frequent 
examinations as we proceed in this part of the operation, while the 
whole is held down, we can keep within the peritoneal covering of 
the uterus. In operating in this way, we should often introduce the 
sound to determine the direction and depth of the uterine cavity above 
the excavation. The sound will serve as an excellent guide to our 
progress. If the vagina is roomy enough, we may sometimes have 
the sound held there most of the time. After we have excavated to 
the desired extent, we should char the surface of the artificial cavity 
with the ther mo-cautery. Dr. H. C. P. Wilson, of Baltimore, has 
invented an ingenious shield, with which the cautery is surrounded, 
to prevent the heat from affecting the parts anywhere except at the 
point of contact. Wilson's shield is a very useful addition to Pa- 
quelin's thermo-cautery. 

This operation should be repeated as soon as evidence of the return 
of the disease is apparent. Often when the cavity of the uterus has 
been curetted free from the epithelial deposit, that organ contracts, 
and, to some extent, obliterates the cavity formed by the excavation, 
and the area of the disease becomes less each time. In such cases we 
may repeat the operation with more prospect of removing the whole 
of the disease than in the first; and even the third or fourth opera- 
tion may thus advantageously be performed. Recent experience leads 
me to attach much importance to the very free use of the solution of 
the pernitrate of mercury. Small pellets of absorbent cotton satu- 



I 



TREATMENT. 473 

rated with that fluid are placed in contact with the scraped surface, 
supported by larger pieces of dry cotton. These large pieces we use 
in such position and in such quantities as to completely protect the 
sound parts, by absorbing the free acid. I am encouraged in this 
Recommendation by the fact that epithelial cancer may occupy the 
rivucous membrane for a long time without vitiating the substructure 
deeply, by high authority, and by the result of my own observation. 

1 prefer this before any other medicine, because it is absorbed and 
acts as a local alterative upon the lymphatics and the juices surround- 
ing the parts. 

Formidable as this operation really is, I have not seen it followed 
by untoward symptoms of any kind. In many cases I have excavated 
the uterus entirely above the internal os until the walls became very 
thin in every direction, and many others to a less extent. Opening 
the peritoneal cavity and bladder is one of the dangers in the progress 
of this operation. This can be avoided by care. Hsemorrhage is 
probably the only other danger, and with Paquelin's thermo-cautery, 
or the galvano-cautery, at hand we can easily check it by touching 
the bleeding artery. 

The operation may be followed by dangerous shock, primary or 
secondary haemorrhage, metro-peritonitis, cellulitis, or septicaemia. 
For the treatment of all these conditions, except haemorrhage, the 
reader is referred to ovariotomy. 

Injections of carbolized water, sufficient to keep the vagina well 
cleansed, is all that will be found necessary to secure the patient from 
blood-poisoning. 

Ordinarily the cavity is filled up in two or three weeks, and the 
wounded cervix covered with a firm cicatrix. In some instances, 
however, the process of malignant degeneration goes on, and we are 
restricted to palliative measures for the rest of the patient's life. 

If extirpation of the uterus is justifiable in any form of malignant 
disease it is so in epithelioma, for that disease is often entirely local- 
ized in the uterus, and yet occasionally so situated that we cannot 
remove the whole of it by any other operation. 

The formidable operation proposed by Freund, and practiced by 
him and his followers, has not been followed by a success that would 
encourage me to perform it under any circumstances. We may rea- 
sonably hope, however, that some method of exsecting the uterus 
which will be less difficult of performance and less dangerous in its 
results may be some day invented. Indeed, a long stride in that direc- 
tion has already been made, and is illustrated by an operation recently 



474 EPITHELIAL CANCER OF THE UTERUS. 

performed by L. C. Lane, M.D., Professor of Surgery in the Medical 
College of the Pacific. Dr. Lane terms his operation pervaginal enu- 
cleation of the uterus. That term alone would mislead the reader, 
for the uterus was not enucleated ; it was extirpated, and the opera- 
tion might very properly be called colpo-hysterectomy, or vaginal ex- 
tirpation of the uterus. 

The operation is very simple, and does not involve the necessity of 
extreme and protracted exposure and handling of the abdominal 
organs. The wounding of tissue is less extensive, and the whole 
operation is done in the lowest and least susceptible portion of the 
peritoneal cavity. 

After placing the patient on her side, in Sims's position, and dilating 
the vagina with Sims's speculum. Dr. Lane had the uterus drawn 
down with Pean's tenaculum forceps, and then made an incision 
through the posterior wall of the vagina. 

" The fundus was then seized by the forceps and the uterus made to 
revolve on its transverse axis, so that the Fallopian tubes and ovaries were 
brought down low in the pelvic excavation in such manner that the base of 
the tubes and accompanying arteries became accessible and easily ligated. 

" Ligation was done with a strong silken cord so passed through but- 
ton-holes (?) in the broad ligaments that they could not afterward slip 
off. This portion of the operation was completed in fifteen minutes, but 
the detachment of the organ from the bladder was long and tedious, but 
finally successfully done without opening that viscus. Yet so thin was 
the remaining vesical walls that the lustre of the catheter, which served 
as a guide, at times could be seen. The organ being removed the pelvic 
excavation was rinsed out with a one per cent, solution of carbolic acid, 
a Nelaton flexible catheter was placed in the bladder, the pelvic excava- 
tion was filled with lint, saturated with four per cent, carbolized linseed 
oil, and the abdomen covered with india-rubber ice-bags. A drainage- 
tube was so fixed alongside the carbolized lint as to allow the escape of 
any fluids which should be passed out from the wounded surface. 

" The convalescence was uninterrupted." 

The description of the operation is very imperfect, yet I think it 
will not be difficult for the reader to follow it understandingly. The 
steps of the operation are : 1. The dilatation of the vagina by Sims's 
speculum. I believe Simon's position and retractors would be better. 
2. Fixing and traction of the uterus downward. 3. Incision of the 
posterior vaginal wall, which should be in the central line and extend 
from the cervix to the recto-vaginal attachment. 4. Bringing the 
fundus uteri down through the vaginal opening by vulsellum 
forceps. 5. Ligating the posterior border of the broad ligament near 



TREATMENT. 475 

the cervix uteri, so as to include the Fallopian tubes, ovarian liga- 
ments, and accompanying arteries. 6. Separation of the anterior sur- 
face of the uterus from the bladder. 

The first two steps of the operation need no further description 
than is given in the quotation. In the third step of the operation a 
fold in the centre of the posterior wall of the vagina should be drawn 
forward by the tenaculum, and incised with scissors. The incision 
should be perpendicular with, instead of across, the vagina, and large 
enough to admit the finger, by which we should be guided in com- 
pleting the opening from the cervix to the attachment with the 
rectum. 

What w^e are to av^oid in making this incision is the wounding of 
a loop of intestine or projection of omentum, which may occupy the 
posterior cul-de-sac, and, while dividing low enough, not to wound 
the rectum. The fourth will be facilitated by traction on the cervix, 
which will bring the fundus downward and forward within reach of 
the finger, and then permit the uterus to be retroverted within reach 
of the forceps. Drawing the fundus forward, up well toward the 
pubis, will so twist and condense the posterior portion of the broad 
ligament as to make the fifth step easy of accomplishment. With 
the posterior border of the broad ligament thus brought forward we 
can easily pass the needle containing the ligature from the vagina 
backward, or from behind forward, and secure the arteries with great 
facility. 

Without some caution another danger is that of including the 
ureters in the ligatures. The ureters approach the neck of the uterus 
in passing to the bladder, and at the anterior part of the cervix are 
within less than three lines. The ligature, therefore, should not be 
more than one-quarter of an inch from the cervix. 

The most difficult part of the operation is the separation of the 
uterus from the bladder. The fibrous coat of the bladder, where it is 
attached to the uterus, is very thin, and great care is required in sep- 
arating it from the uterus not to open the bladder. The direction 
given by Freund should be remembered. He recommends making 
an incision across the anterior surface of the uterus, through the peri- 
toneum and connective tissue. Then by means of the finger or handle 
of the scalpel, strip the bladder off from the uterus. When the point of 
vaginal attachment to the uterus is reached it may be carefully sepa- 
rated with the knife or scissors. The separation of the neck from the 
vaginal attachment and the side will be easy after the bladder is iso- 
lated. 

It seems to me that the operation of Dr. Lane would have had a 



476 EPITHELIAL CANCER OF THE UTERUS. 

better conclusion if he had closed the wound either with silk or wire 
sutures. The most of the large opening ought certainly to be closed 
in this way^ and if the operation is performed under carbolized spray 
it would be better thus to unite the whole of it. 

Should we desire to amputate the body from the cervix this 
method of bringing the uterus out of the peritoneal cavity would 
give us an excellent opportunity with the minimum risk. 

A question very naturally presents itself in this connection^ Should 
we leave the ovaries in the pelvis after removing the uterus ? 

Redner explains how the favorable results in ovariotomy led also 
to the removal of myoma and carcinoma of the uterus by laparotomy, 
and then how more recently the unfavorable results of the method of 
operating advocated by Freund led to a neglect of laparotomy. This 
change was favored also by the fact that the large number of cancers 
springing from the cervix uteri could only be removed imperfectly 
and with difficulty by this method, hence we have drifted back to the 
older practice of attacking the organ through the vagina. Eedner 
himself operated several years ago in twenty-eight cases of carcinoma 
uteri through the vaginal wall, with almost invariable success (only 
three deaths, two by Infection, one by haemorrhage), by supravaginal 
excision of the cervix. And once having gone so far it was but a step 
to remove the whole uterus through the vagina. This procedure has 
recently been carried out almost simultaneously by Billroth, Czerney, 
and Schroeder. Eedner himself has operated in this manner on six 
cases within the last month, and his assistant, Hofmeyer, operated 
successfully, in a clinic, a seventh one. Out of these seven cases 
only one patient died, of internal hsemorrhage from a rupture of the 
ligamentum laterum uteri. 

Schroeder gives a short description of the steps of the operation. 
A Museux forceps is fastened upon each lip, the vaginal wall cut 
through, and all connection with the bladder broken up by the finger, 
in order to avoid any Injury of the ureters allowing them to escape 
upwards; then, through an incision Into the cul-de-sac of Douglas, 
the posterior connections of the uterus are severed and the uterus 
turned out through the opening, drawn down by means of the forceps, 
and cut off near the ligamentum lata. The arteries, which are thereby 
very much stretched, must be ligated. The ovaries and tubes are not 
taken out by Schroeder, because otherwise the ligament-stumps (espe- 
cially the ligamentum infundibulopelvicum) become so short that their 
ligation is very difficult, and secondary haemorrhage liable to occur. 
He ligates the vessels of the ligaments en masse, sews the stumps to 
each side of the vaginal incision, and carries a drainage-tube through be- 



TREATMENT. 477 

tween them. After the necessary cleansing the antiseptic bandage is 
applied. 

The prognosis is not only considered good by Schroeder because 
the mortality figure is so small, but also because the convalescence is 
so rapid and easy, for in the cases cited only two showed slight fever 
and two others mild symptoms of collapse. 

As to the indications for such operative measures, Schroeder advises 
against interference when the cellular tissue of the pelvis is already 
invaded by cancer, which must be determined by careful palpation. 
He further calls attention to the fact that the larger the diseased 
uterus the greater will be the difficulties by this method, and the more 
appropriate will Freund's procedure become, and, at the same time, 
that in cases of cancer of the cervix situated low down we should be 
more conservative in either enucleation or supravaginal excision ; yet 
after all, notwithstanding all of the advantages of the new procedure, 
the former methods would still retain their merits, according as they 
might be selected in particular cases. 

In Martin's three cases he found such difficulty that in only one 
case was the operation complete. 2d case : Impossible to sever all 
adhesions; portion of diseased tissue remained behind. 3d case : Same 
kind of difficulty ; conclusion that firm adhesions and brittleness or 
friability of the uterus contraindicate the operation. 

Interrogated by Meyerbeer, Schroeder says he closes the vaginal 
opening with curved needle and silk, but recommends ligation of 
ligaments by wire. 

Baum (of Danzig) says he formerly operated successfully by supra- 
vaginal incision seven times, without resulting fever, that in only 
two cases had he failed to find a return, but in the last few months had 
operated per vaginam four times, two of the cases resulting in death 
from shock and septic peritonitis. He operated after Billroth's manner, 
and in one case removed the ovarian tubes, but applied no sutures in 
order to allow better drainage of the secretions. A drainage-tube was 
introduced, through which, in case of fever, the parts were washed out. 

Schroeder favors sutures which do not render septicsem-ia more 
liable and insure against protrusion of intestines.* 

Baum prefers his method, and thinks protrusion of intestine can be 
prevented by position. 

* Paper read by Schroeder (Berlin) on "Total Extirpation of the Uterus per 
Vaginam" in the gynaecological section of the fifty-third Versammlnng der deutsche 
Naturforscher und Aerzte in Danzig, in September, 1880. Reported in the Archives 
-uer Gynaecologie Sechszehnter Band, Drittes Heft. 



CHAPTER XXXII. 

SARCOMA. 

AxoTHER variety of malignant disease of the uterus is sarcoma. 
It generally shows itself in the form of a tumor, developed at the 
expense of the fibrous structure of the uterus, an apparently isolated 
portion of which is infiltrated by an abundance of peculiar cells. 

While not encapsulated, like the fibrous tumors, these growths dis- 
place the surrounding tissue, and protrude in a submucous or sub- 
serous direction until they become, to a greater or less degree, 
pediculated. When first discovered and described these tumors were 
denominated recurrent fibroids, because ablation did not destroy them. 
Their recurrence is, doubtless, due to the fact that, while apparently 
isolated, the neighboring tissues are permeated by the sarcomatous 
cells. Instances of diffuse sarcoma are also sometimes met with 
when all the tissues of the entire uterus are infiltrated. 

The cases of diffuse sarcoma with which I have met have all 
belonged to the small-celled variety, and the process of degeneration 
has spread from the uterus to the surrounding tissues, invading es- 
pecially the connective tissue of the broad ligament. Sarcoma is a 
less frequent disease than carcinoma or epithelioma. 

Symptoms. 

Its early clinical history is very similar to that of the fibrous tumor, 
and is more generally mistaken for it than any other growth. Serous 
leucorrhoea, metrorrhagia, and enlargement are the main ones. Its 
course is usually rapid, less so, perhaps, than cancer, and more so 
than fibrous growths. In some cases it attains to a large size before 
any peculiar phenomena appear. After a time, especially if sub- 
mucous or polypoid, it begins to break down, the discharge becomes 
offensive and copious, and the disease proves fatal in much the same 
way as cancer. 

The general symptoms in the early periods of development are 
not marked, and thev onlv become so after the tumor has ^rown larg^e 
enough to interfere by pressure with the fecal and urinary excretions, 
or in breaking up furnish septic material in such quantities as to 
induce septicaemia, when all the disastrous symptoms of that formid- 



i 



DIAGNOSIS. 



479 



able fever are established. Thus diarrhoea, copious perspiration, 
elevated temperature, rapid pulse, failure of the assimilative func- 
tions, and great nervous prostration tend to a fatal issue with as much 
certainty as any other of the malignant affections. 

Diagnosis. 
In the commencement it is always difficult to arrive at a correct 
diagnosis. The symptoms are not characteristic, and until the com- 
mencino; dissolution of the tumor are as much like those of fibrous 
tumor as they are like carcinoma, and when disintegration begins 
they thoroughly simulate cancer or epithelioma. The only sure diag- 
nostic sign of sarcoma is afforded by the microscope. A portion of 

Fig. 145. 




From Coriiil and Ranvier. 

the tumor should be submitted to microscopic examination, when the 
characteristic cell may at once be discovered (Fig. 145). 

Mr. Butlin* makes the following histologic distinction between 
sarcoma and carcinoma. He says : 

" I should, then, define carcinoma to be a tumor of epithelial origin, 
having generally an alveolar structure, and sarcoma a tumor of con- 
nective tissue origin, formed generally of embryonic tissues, and without 
alveolar structure. And, for the minor differences, the cells of carci- 
noma generally resemble those of the epithelium from which it grows ; 
there is little intercellular tissue; the vessels run in the fibrous tissues, 
not among the cells ; and multiplications of cells is by endogenous forma- 
tion. On the other hand, sarcoma is composed of round or fusiform or 
giant cells, and these are packed, in a more or less abundant basis ; the 
vessels are often mere fissures between the cells, and the cells increase in 

* Lectures on the Relation of Sarcoma to Carcinoma, by Henry Trentham But- 
lin, F.R.C.S. American reprint. London Lancet, February, 1881. 



480 SARCOMA. 

number by division. These minor characters are common, but they are 
not constant. One or other of them may be absent in a tumor of either 
class ; or, worse, may be present in a tumor of the other class. More 
commonly it is sarcoma, which simulates the appearance of carcinoma; 
but, fortunately, this feigning takes place most often in textures where 
there can be no question of the origin, and therefore of the nature, of the 
tumor. The alveolar structure, found in some sarcomas, is rarely so 
perfect as that of most epithelial tumors ; indeed, careful study dis- 
covers that the tissue which surrounds the alveoli is generally formed of 
spindle cells. There is, in most cases, no real difficulty in assigning each 
tumor to its class." 

Prognosis. 

The prognosis is no more favorable than that of cancer. While in 
many instances the tumor caused by the morbid growth seems to be 
quite isolated^ the cells penetrate the surrounding tissue to such an 
extent as not to be eradicable. 

The contamination of the surrounding tissue does not seem to take 
place by absorption and transmission of the cells, or debris of the 
sarcomatous cells, but to be due to the insinuation of the cells into the 
contiguous substance surrounding the growth. It is, probably, 
always local in its origin and progress. This consideration, if true, 
would encourage us to hope that, by ablation of all the morbid sub- 
stance, we might arrive at a cure. 

Treatment. 

To be radical the treatment should consist of the entire removal of 
the growth. I have seen no cases in which any operation has re- 
sulted in more than temporary benefit. When the disease is confined 
to the uterus, I think the most rational treatment would be the re- 
moval of that organ. Hysterectomy would seem to me to be more 
promising in sarcoma than in carcinoma. 

In addition to the general palliative treatment, detailed under the 
head of cancer, the removal of sloughing masses by the curette and 
scoop, we will often derive great benefit from the free administration 
of ergot. The contraction of the uterus, under the influence of 
ergot, will do more to clear out the softening mass from its cavity 
than any instrumental interference. I have in several instances 
removed the sarcomatous growth by ergot so thoroughly that the 
improvement of the patients' health led them to hope for ultimate 
recovery. When the growth is submucous, and of the most friable 
variety, I would fully expect it to be expelled by ergot. It does not, 
however, affect the spread of the growth, and ultimate fatal result. 






CHAPTEK XXXIII. 

TUMOKS OF THE UTERUS. 

Any organized growth within the substance of the uterine walls, 
or depending from or connected with any of its surfaces, may be 
called a tumor. This definition will include polypi of all varieties 
and sizes, from the mere granule that renders the mucous surface 
irregular by its protrusion, to the growth which fills up the uterine 
cavity. 

Fibrous Tumors. 

Fibrous tumors of the uterus are homologous growths. They are 
not pure hypertrophies of certain parts of the uterine tissues. As 
proof of this the tumor-tissue exhibits too much of the rudimentary 
character of fibres of the undeveloped kind, and there is not a uniform 
proportion of the different constituent elements. For instance, we 
find that sQme specimens are quite firm and resisting, while others 
are frail. In the firmer variety, the fibrous element is more abundant 
than the connective, and these ought to be denominated myomatous 
or muscular fibrous tumors, while the term fibroma would be better 
adapted to those tumors in which the fibres of the connective tissues 
preponderate, and the tumor is softer. 

The question very naturally arises : How do those tumors origi- 
nate ? A question that cannot be satisfactorily answered. What we 
know about their "habits" I will lay before the reader. They 
occur more frequently in persons between the age of thirty-five and 
fifty, and are found oftener in women of African descent than in 
those of European or Asiatic origin. From much observation I am 
also persuaded that the long continuance of great hypersemia of the 
uterus strongly predisposes patients to fibrous tumors. Hence, we find 
them connected with sterility, dysmenorrhoea and menorrhagia. I 
know that these conditions are often the results of fibrous degeneration, 
but I have had opportunity of watching many such morbid states of the 
uterus, which, while giving rise to other symptoms, were constantly 
attended with hypersemia. In some such cases after years of suffering 
tumors were developed. One remarkable instance is in a patient who 
has been under my eye for fifteen years. She is a maiden lady, now 
forty years of age. A few years after she commenced to menstruate, 

31 



482 



TUMORS OF THE UTERUS. 



she became subject to hypersesthesia and hypersemia of the uterus. 
Although I saw her, and made examination of the uterus several 
times a year during these fifteen years, I discovered nothing which 
induced me to suspect fibrous growth until three years ago. Then I 
could easily make out a tumor, with two nuclei of development in 
the anterior wall of the uterus. When first noticed, the tumor was 
half as large as an orange. It grew to four times that size in the 
next twelve months. I have seen so many cases similar to this that 
I cannot believe hypersemia and the development of the tumor to be 
a mere coincidence. We know that prolonged hypersemia is one of 
the necessary conditions of hypertrophy, and it is hardly possible to 
have hypertrophy without hyperplasia. It would seem, indeed, to 
be the hypertrophy of the vortices or foci of muscular gyrations in 
the undeveloped condition of the fibrous structure which leads to the 
formation of these tumors. 

Fig, 146. 




All fibrous tumors of the uterus have their origin in the wail of 
the organ. Some arise immediately in contact with the mucous 
membrane, then begin to intrude themselves into the cavity of the 
uterus as soon as they begin to grow, and become pediculated while 
yet small, d. Others commence their growth beneath a very thin layer 
of fibres, a. These are quite near the mucous membrane, but not in 
immediate contact with it. They very soon overcome the resistance 
of the thin layer of fibres, and pushing the mucous membrane before 



NATURE OF TUMORS. 483 

them, become pediculated later in their growth. If, however, they 
are deeper in the wall, but nearer the mucous than the serous surface, 
the larger part of their bulk encroaches gradually upon the interior 
of the uterus, forming broad tumors that fill the cavity. They can 
easily be recognized by the finger after dilating the cervical canal. 
All of these varieties are submucous tumors, but in common profes- 
sional language the first two are called polypi, while to the last the 
term submucous tumor is generally given. The term intramural is 
used to indicate the tumor that arises in the centre of the uterine 
wall, B ; a tumor which in its development displaces the surrounding 
tissues alike in every direction. In point of fact the exact central 
mural tumor is very rare, the great majority having their nidus ex- 
ternal or internal to the central layer. The subserous tumor varies 
in its relative distance from the peritoneal surface in the same manner 
as the submucous from the lining membrane of the uterus. Hence, 
some of them spring from the outer surface of the uterine wall, are 
suspended by a very slender pedicle, and covered only by the peri- 
toneum, E. Others are not so pendulous, but still are enveloped by 
only a very thin layer of fibres externally. If they are still more 
remote from the peritoneal surface, they merely show themselves as 
bulky protuberances on the outside of the uterus, c. One more state- 
ment with reference to position. They are usually developed in the 
wall of the body, and comparatively seldom have their origin in the 
cerv^ical portion of the uterus. This statement is true of every variety. 

Their Nature. 

A dissection of these tumors enables us to discover that they are 
surrounded in most instances by a well-marked capsule. It ought 
not to be called a cyst, for it has not a separate organization, and it is 
formed by the tissues surrounding the tumor, being compressed as 
they are displaced, until the inner surface of the cavity becomes 
smooth. At a number of points the capsule and surface of the 
growth are connected by frail fibrillae and vessels. The number and 
magnitude of these connecting fibres and vessels vary, but it is ex- 
ceedingly uncommon for vessels of considerable size to enter any of 
these tumors, and the vascular supply is proportionately small. From 
these facts the logical deductions, namely, that fibrous tumors of the 
uterus are of slow growth, of low vitality, and not usually reproduced 
from their capsule, are corroborated by observation. The source of 
their nutrition, or their vascular supply, is diffuse, coming through 
many small channels at various points in their periphery, and not, as 



484 TUMORS OF THE UTERUS. 

in the ovarian tumors, from one great artery. Such a supply is the 
cause of a somewhat definite period of vitality. It is not capable of 
maintaining the growth to an indefinite degree, and a disturbance of 
its nutrition may easily occur. Thus, after they attain a certain 
magnitude, they are likely to stop growing, and in many instances 
they degenerate into a lower form of tissue, resembling cartilage, or 
even to descend still lower in the scale of vitality, and be partially 
changed into a cretaceous deposit. Again, their low vitality subjects 
them to the process of inflammation or eremacausis. Inflammation, 
resulting in gangrenous disintegration, is one of the accidents that 
sometimes brings about their discharge and cure. At other times it 
occasions the death of the patient during the complicated consequences 
thus arising. I have witnessed both of these terminations. The 
fibrous tumor of the uterus is frequently multiple. 

The position occupied by the growth is accompanied by a number 
of important effects. When situated in the centre of the wall — intra- 
mural — it grows more rapidly than when in the subserous portion 
of the fibrous structure, but probably not so vigorously as when nearer 
the mucous membrane, or when it belongs to the submucous variety. 
In fact it will generally be found that the nearer the peritoneum 
the nucleus of origin, the more slowly will the tumor increase in 
size. We also find that the intramural and submucous varieties 
cause the uterus to grow and become vascular with much greater cer- 
tainty than the subserous. Indeed, we often find very large subse- 
rous tumors growing from a uterus of comparatively small dimen- 
sions. The tumor may be not less than ten times the size of the organ 
to the fundus, of which it is attached. If a tumor of this size w^ere 
developed in the centre of the wall of the body of the uterus, the 
depth of the cavity would be not less than six inches. While the 
uterus in such cases is more than ordinarily vascular, it is not so 
much so as it would have been if the tumor had belonged to the in- 
tramural variety. Of course the polypous, or submucous tumor, de- 
velops the uterus with more uniformity than the intramural variety. 
The uterus, in the cavity of Avhich there is a polypus, grows with 
nearly the same symmetry as if pregnant. 

It logically follows from these facts that the submucous and intra- 
mural varieties are the most mischievous, as the more rapidly the 
uterus grows, the more certainly will it do mischief by pressure; and 
the more vascular the uterus becomes, the more haemorrhage will 
occur. And we find from observation that these inferences are cor- 
rect. 



NATURE OF TUMORS. 485 

Again we find that developed in certain zones of the organ their 
behavior and effects are different. Fibrous tumors comparatively 
do not often originate in the cervical portion of the organ, and when 
they do their growth is not very rapid, nor do they cause the uterus 
to become very large. In the corporal zone they grow most rapidly, 
cause the uterus to enlarge faster, and do more mischief. Lastly, in 
the fundus their activity of growth is less rapid, and produce less 
morbid changes upon the organ. 

In examining uteri containing fibrous tumors, which have fallen 
under my observation, I have noticed that the character, as well as 
the degree of its development, has varied quite considerably. 

The growth of the fibrous structure of the uterus is not exactly the 
same in character and degree as in pregnancy. The fibres are cer- 
tainly enlarged, and they become muscular, but in very few localities 
do they attain to the same perfection as in pregnancy. 

In the subserous variety they do not anywhere attain to the per- 
fection of pregnancy, and are usually quite rudimentary in their 
character. Nor do they possess much contractile power. In the in- 
tramural tumors the fibres surrounding the growth attain much 
greater dimensions, and acquire great power. Seldom, if ever, how- 
ever, do they assume all the qualities of the fibres in the gravid uterus 
at term. In these cases the fibres in the opposite wall do not keep 
pace with those surrounding the tumor. In the submucous variety 
the fibres external to the tumor in the same side in which they origi- 
nate are largely developed, while those between the tumor and mu- 
cous membrane attain considerable length, but are attenuated, and 
lack strength. This is one reason why they are pushed into the cavity 
of the uterus. 

When the tumor is polypoid, and occupies the cavity of the uterus, 
especially if it comes from the body near the fundus, filling up and 
distending the cavity of the body in every direction, it causes great 
uniformity of development of the fibres. The fibres all around grow 
more as they do in the pregnant uterus, attain great power, and usually 
expel the growth into the vagina. 

Very nearly the same statements may be made in reference to the 
growth of the vascular system in the different varieties of tumors. 
The vessels are more enlarged on the side occupied by the tumor in 
the intramural and subserous than on the unoccupied side. They are 
more generally enlarged in the intrauterine polypus. 

It may be further stated that a single tumor grows more rapidly, 
causes greater vascularity in the uterus, and brings about greater 



486 TUMORS OF THE UTERUS. 

hypertrophy of the fibres of the uterus than the multinuclear fornn. 
Indeed, were numerous points of growth to commence at the same 
time, although great bulk may be attained, the bulk consists in the 
morbid deposits more than in the growth of the physiological struc- 
ture of the uterus. This is so markedly the case that after a certain 
time this kind of tumor stops growing for the w^ant of vascular sup- 
ply, and becomes transformed into a dense tissue of a vitalit}^ far be- 
low that in the single tumor. It sometimes becomes a true fibroid 
deo^eneration of the whole uterus, in which it would be hard to trace 
any of the anatomical elements peculiar to that organ. 

Symptoms. 

From this exposition of the growth and effects of tumors upon the 
surrounding structures, it will be readily inferred that the symptoms 
observed in connection Avith fibrous tumors of the uterus are not the 
same, and must vary greatly in the different varieties. The most 
frequent symptom is haemorrhage, either at the time of menstruation 
or during the intervals. In the early periods of the growth the pa- 
tient will observe profuseness in the menstrual flow, and some cases 
occur in which this is the only time when there is loss of blood, but 
in very many instances the losses take place at irregular intervals, 
and sometimes the discharge is so irregular that the patient will lose 
her knowledge of the time when she ought to be unwell. In quite 
a large proportion of cases there is no deviation from the ordinary 
habit of menstruation. The patient is regular. 

The variations of this hsemorrhagic symptom conform, in general, 
to well-known conditions, and we may expect to find the haemorrhage 
more profuse th^ nearer the tumor is situated to the mucous mem- 
brane. In hsemorrhagic cases we shall also find that the size of the 
tumor has much to do wdth the flow. The larger the tumor, other 
things being equal, the greater the haemorrhage. Large submucous 
tumors will, therefore, cause more profuse haemorrhage than any other 
sort. In estimating the value of the rule in the correspondence of 
these conditions, we must remember the frequent coexistence of small 
submucous with large subserous tumors, and that, as there are excep- 
tions to all rules, we may sometimes have profuse haemorrhage in 
subserous, and small losses in submucous tumors. The latter excep- 
tion, however, is very rare. 

Leucorrhoea, consisting of thick, tenacious mucus, from the cer- 
vical cavity, is perhaps the next most frequent symptom, and it is 
generally governed by the same rules with respect to frequency and 



SYMPTOMS. 487 

profuseness as metrorrhagia, being greater in quantity in submucous 
than subserous tumors. 

Watery discharges from the uterus are also a common and signifi- 
cant symptom. They occur more frequently just after, and appear 
to be supplemental to, the hemorrhages; and I must observe with 
reference to them, also, that they are usually more profuse in sub- 
mucous tumors. It will be observed that all the discharges — hsem- 
orrhagic, leucorrhoeal, and watery — show themselves under the same 
circumstances, and there is a very good reason for this, which I men- 
tion in passing. The cases in which the tumors are so situated as to 
greatly increase the vascularity of the uterus, are also the cases in 
which these discharges are more profuse. 

Dysmenorrhoea is not so commonly met with as the three symp- 
toms already mentioned. When it does occur it is of the obstructive 
variety. It is manifested by cramping pain recurring at intervals. 
We may account for its assuming this phase by the fact that the tumor 
encroaches upon the cavity of the uterus and renders it tortuous, and 
in some cases occludes it by forcibly pressing the sides together. The 
blood is accumulated above these obstructed places, and the pains are 
caused by the efforts of the uterus to expel the blood thus imprisoned. 

The subserous tumor is the only kind that may not occasionally 
cause dysmenorrhoea. It is probably more frequently present where 
there is a number of nuclei of development, some of them being sub- 
mucous. 

Among other symptoms, I wMsh particularly to call attention to 
that of presmre. It begins very early in the progress of these growths, 
and is quite often noticed. The first evidence of pressure is suffering 
in the pelvis. When the tumor first becomes enlarged, the uterus 
presses upon the perinseum, and this pressure causes a feeling of un- 
usual weight in that region. This ^'bearing-down sensation'^ may 
increase until, finally, the uterus and vagina may protrude through 
the vulva; the womb may also fall backwards upon the rectum and 
produce tenesmus or other uneasiness in that organ; and not unusu- 
ally haemorrhoids are thus developed with their attendant symptoms. 
Should anteversion occur, the bladder will suffer from the pressure 
in the various forms of clysuria, and even inflammation in that viscus. 
When the tumor is located in the posterior wall, the uterus is retro- 
verted; when in the anterior, it is anteverted. When the organ is 
enlarged equally in all directions, it will be prolapsed. As it enlarges 
so as to fill up the pelvis, the pelvic veins are sometimes so pressed 
upon as to retard their circulation, and there may arise varicosity in 



488 TUMORS OF TOE UTERUS. 

the legs, anus, vulva, and surrounding parts. The nerves suffer from 
the pressure in such a way as often to manifest sciatica, and crural 
and vulvar neuralgia. 

When the tumor is large enough to rise out of the pelvis, it may 
cause pressure upon the abdominal viscera, and by its bulk, hardness, 
and irregular shape give rise to great inconvenience from distension 
of the abdominal cavity, producing more suffering than the same dis- 
tension from most other causes. 

Several important complications are likely to result from pressure, 
such as inflammation of the pelvic viscera, cystitis, rectitis, cellulitis, 
and local peritonitis. I need not stop to give the symptoms of these 
complications, as they are the same as when arising from other causes. 
The pelvic inflammation sometimes extends to the veins passing 
through the cavity, and gives rise to phlegmasia alba dolens. 

Abdominal inflammations also complicate these cases, some forms 
of peritonitis especially. A moderate peritoneal inflammation may 
result in serous effusion, and the ascites sometimes gives rise to more 
trouble than the tumor, being in some cases the immediate cause of 
the fatal result. 

The consideration of the effects caused by pressure exerted by these 
tumors leads me to the subject of their progress and development. 

It may be said of them, in a general way, that their growth is slow. 
This is especially so as compared with most other growths. In very 
many cases it requires years for them to attain a magnitude suflicient 
to endanger the patient's life. Indeed, some patients carry them 
through a long life without experiencing more than a slight incon- 
venience. Occasionally exceptional instances occur, however, in which 
the growth is rapid and very destructive. 

The conditions which promote their growth are now pretty well 
understood, especially the general proposition : that the more vascu- 
lar the uterus becomes from any cause the more rapid their growth. 
The converse of this statement becomes a necessary corollary. 

They grow rapidly during pregnancy. During the period of life 
in which the menstrual discharges occur in a normal way, the tumor 
grows more rapidly than after the menopause. The submucous in- 
crease in size with more rapidity than the subserous, and the tumor 
centrally located in the uterine wall generally requires for its devel- 
opment a period of time which may be regarded as a mean between 
the other two. The multiple ones advance more slowly than the 
single tumors. There is one circumstance which may add greatly to 
the vitality of any of these growths, and consequently cause them to 



DIAGNOSIS. 489 

grow with great energy. I allude to adhesions to the visceral or 
parietal peritoneum. When extensive adhesions occur, the vessel of 
the adherent surface penetrates the uterine tissue and greatly increases 
its vascularity. This is so remarkably the case in rare instances, that 
the peritoneal surface of the tumor becomes reticulated with large 
vessels. The growths thus usually become very formidable. Occa- 
sionally, tumors that have grown so slowly as to seem stationary in 
this respect, suddenly start up, and their behavior is entirely changed. 
We see this in subserous tumors in a remarkable manner. It is 
hardly necessary for me to remind the reader that this change is 
generally preceded by inflammation, and that this is the cause of 
adhesions. 

When the tumors, as sometimes happens, undergo interstitial de- 
generation in such a manner as to cause cavities in their substance, 
they grow rapidly by an accumulation of fluid in these hollow spaces. 
This change constitutes a new variety, which is called fibro-cystic. 
They often become very large, grow very rapidly, and are mistaken 
for ovarian tumors. Some of our most expert specialists have been 
betrayed into their removal under this misapprehension, and have 
been made aware of their mistake only after a careful examination 
subsequent to their extirpation. 

Diagnosis. 

We learn, after much observation, that the history and symptoms, 
although very important items in the diagnosis, are not sufficient to 
establish it, hence we are obliged to resort to physical examination. 
Another observation may be made in this connection; the greatest 
difficulties in forming a correct diagnosis will be experienced in 
tumors of each extreme in size. The medium-sized tumors may be 
diagnosed without much trouble. In cases of small-sized tumors we 
cannot always determine without much care whether the enlargement 
of the uterus is due to a tumor or some other cause. In such cases 
the depth of the uterus should be measured by the sound. While 
the sound is in the uterus, and that organ held in its normal posi- 
tion, the finger is to be passed as high as possible into the rectum, 
and the posterior wall thoroughly explored. If there is a tumor in 
that part it will be found thickened and nodulated. Should this not 
be the case a male catheter should be introduced into the bladder, and 
the anterior wall of the uterus carefully surveyed. If the symptoms 
are sufficiently grave to excite apprehensions, and yet leave an un- 



490 TUMORS OE THE UTERUS. 

certainty, the finger may be passed into the bladder instead of the 
catheter ; otherwise it should not be used. 

To ascertain the existence of a small intrauterine or submucous 
growth the cervix should be dilated with sea-tangle, or compressed 
sponge- tent, until the finger can be passed into the cavity of the body, 
when there will be no difficulty in finding the tumor. iSTone of these 
proceedings are justifiable, if there is tenderness or other signs of 
general inflammation of the uterus. 

It is more frequently the case that the tumor is evident, and then 
the object is to ascertain if it is uterine. To determine this question 
it is necessary to discover its attachments. This may be done by 
placing one finger on the mouth of the uterus, and another in the 
rectum to move the tumor. If it is attached to the uterus they will 
move together. We should be careful, in making this kind of an 
examination, to make the movements vary in direction ; if possible, 
the tumor should be moved from the uterus, or upward, or down- 
ward. The tumor ought to carry the uterus with it when moved in 
any direction. If the sound is passed into the uterus, and the tumor 
moved afterwards, the instrument, as may be seen, will very plainly 
indicate the movement of the organ. The cavity will also be in- 
creased in length. When a tumor is large enough to be felt above 
the pubis the attachment will be more easily made out by moving it 
with the hands pressed upon it from above, while the sound is in the 
cavity, or the finger on the cervix. 

The second most important diagnostic indication is the firmness of 
the tumor. The fibrous tumor is usually hard and not elastic. 
Another almost essential circumstance has just been alluded to, viz., . 
the increased depth of the uterine cavity. The history of the case 
will generally enable us to decide, whether the tumor under exami- 
nation is one caused by inflammation or not; the inflammatory 
tumor moreover is seldom movable. A haematocele is behind the 
uterus, is elastic, and has the shape of the cul-de-sac, instead of being 
globular. 

When the tumor is large enough to fill up the abdominal cavity, 
and become immovable in consequence of its bulk, it is not always 
but usually elastic. If so, it has become fibro-cystic. We cannot 
always determine the relation of these tumors to the uterus by the 
methods I have described. Often we are unable to introduce a sound 
into the uterine cavity, in consequence of its tortuous direction, and 
the diagnosis becomes extremely difficult. These are the tumors, as 
I have before said, that have been mistaken for and removed as 



PROGNOSIS. 491 

ovarian tumors. Probably the only positive way of clearing up the 
diagnosis, is to draw off some of the fluid with a trocar, or aspirator, 
and make its character the test. Dr. Washington L. Atlee, of Phil- 
adelphia, in his admirable work on the diagnosis of ovarian tumors, 
has furnished us with a description of the fluid derived from this 
kind of fibrous tumor, that is every way correct. The fluid does not 
run out of the canula of the trocar with the facility with which the 
ovarian fluid is evacuated, and often when it is received in a vessel, 
and becomes somewhat cool, it coagulates, and like blood separates 
into clot and serum. When examined by the microscope, debris of 
blood-corpuscles and fibrillse of fibrin are the characteristic substances 
found. One other circumstance I have failed to call attention to is, 
that fluctuation observed upon percussion is less decided than in 
ovarian tumors. If the tumor is larw enouo;h to distend the abdo- 
men, it may be complicated with peritoneal dropsy. This condition 
also renders the diagnosis obscure. Tapping will generally enable 
us to arrive at correct conclusions. After the ascitic fluid has been re- 
moved, an examination of the tumor will enable us to establish its 
relations to the uterus, as well as determine its density and shape. 
The fluid in these cases should be submitted to microscopic exami- 
nation with a view to ascertain whether it came from an ovarian 
cyst or the peritoneal cavity. 

Prognosis. 

There are several considerations which render the general prog- 
nosis favorable as compared with other tumors for which they may 
be mistaken. 

They occur generally in persons who have made a near approach 
to the menopause, and generally they cease growing after this con- 
dition is passed. They grow slowly, and may not be expected to 
arrive at dimensions sufficiently great to cause fatal consequences for 
many years, if ever. They often stop growing without any discover- 
able reason ; they sometimes undergo degeneration into inert masses, 
which remain as mere inconvenient bodies. jS^ature sometimes gets 
rid of them by expulsion, or they may be protruded from the uterus 
into the vagina, within reach of surgical measures. Lastly, many of 
them disappear under judicious medical treatment, or all the 
threatening symptoms attendant upon them may be removed by such 
means. 

Almost none of these conditions obtain in ovarian tumors and 
very few in any others found in the same locality. These considera- 



492 TUMORS OF THE UTERUS. 

tions ^'ill establish the conclusion that the general prognosis is favor- 
able. 

The circumstances which in individual cases form an unfavorable 
prognosis are : the youth of the patient, as they usually grow more 
rapidly in young persons; the rapid growth of the tumor; hsemor- 
rhagic symptoms; unfavorable complications, as peritoneal dropvsy, 
inflammation in the pelvis or abdomen, pressure upon the pelvic or- 
gans, nerves, or vessels; inflammation of the tumor, impaction in the 
pelvis, uraemia, anaemia, pregnancy, ovarian tumor, etc. The fibro- 
cystic variety possesses several elements of danger ; its rapidity of 
growth being the cause of several others, as pressure, impaction, 
dropsy, etc. 

The complications of pregnancy and labor with fibrous tumors 
of the uterus is one of sufficient importance to demand special 
consideration, especially as we may be obliged to determine a course 
of action when the emergency leaves no time for research. The 
simple coexistence of a fibrous tumor with pregnancy is not suf- 
ficient reason for interference, and I am persuaded from personal 
observation that there are but few cases which call for any interfer- 
ence whatever. 

I do not wish to be dogmatic, but I desire to make a few definite 
statements of what I regard as facts. Pregnancy takes place more 
frequently when the tumor is situated in the central zone of the 
uterus and remote from the mucous membrane ; but it will not occur 
if the tumor belongs to the submucous variety, although it is in the 
middle, or even in any part of the uterus except the cervical portion 
of the inferior zone. I have already intimated that there are very 
few large tumors developed in the inferior or cervical zone compared 
with those that arise from the central corporeal and superior or fun- 
dal zone, and that such as these are usually developed in the submu- 
cous tissue and are generally pendulous — these do not appear to in- 
terfere very much with pregnancy. From what I can learn and 
have observed pregnancy seldom, if ever, takes place when the tumor, 
being of more than moderate size or situated near the mucous mem- 
brane, is located in the fundus or upper portion of the superior zone. 
In general the larger the tumor the less likelihood of pregnancy, and 
if it does occur the impossibility of normal uterine development leads 
to abortion. 

The dangers to be apprehended arise usually at the time of labor 
and consists: 1, In the obstruction to delivery caused by the tumor 
blocking up the pelvis; 2, in the incomplete contraction after deliv- 



PROGNOSIS. 493 

erv failing to close up the placental vessels, and thus causing grave, 
if not fatal, haemorrhage. Tumors situated in the superior zone, the 
middle zone, or the upper portion of the inferior zone will offer little 
obstruction, because the head will have passed them above the pelvic 
brim. This leaves but a limited number and those small in size that 
are crowded down into the pelvis by the side of or before the fetal 
head ; they are the submucous or polypoid variety situated in the 
cervical portion of the inferior zone. Such tumors are generally 
pressed entirely out of the vulva and permit the head to pass out after 
them. I may mention, in passing, that they may sometimes be de- 
tached from their base by the pressure of the head ; or, remaining 
intact, may be retracted within the pelvis after the labor is over. 

The second danger is, I think, very much overrated. The fact of the 
fibrous tissue of the uterus having been developed sufficiently to permit 
of the completion of gestation is an evidence that it is sufficiently pow- 
erful to contract fully, and one single case recently published by Dr. 
Chadwick, of Boston, in which the placenta was implanted on the 
uterus over the seat of the tumor, and in which haemorrhage did not 
prove serious after delivery, goes far to prove that great danger from 
this cause is not likely to occur. In no case of labor associated with 
a tumor Avhich has come under my own observation has hsen^orrhage 
been a grave symptom. 

It is fair, I think, in the light of our present knowledge, to infer 
that it is seldom necessary to interrupt pregnancy when complicated 
with fibrous tumors of the uterus, as, in the nature of things, gesta- 
tion will not continue unless there is sufficient integrity of uterine 
tissue to permit ample development. At the time of labor the indi- 
cation for operative procedure will appear in the want of progress, 
and then the obstacles may be surmounted by turning, or forceps, if 
the propulsive powers of the uterus are not sufficient. Common pru- 
dence will incite to vigilance in preventing haemorrhage in these as 
in other complicated cases of labor. It will be observed that while 
I cannot ignore the importance of watching these cases attentively, I 
am far from considering them as necessarily very dangerous. 

Another question of great importance is, what effect does preg- 
nancy and labor have upon the tumor ? 

In a minority of cases none whatever. The tumor remains the 
same after the pregnancy has terminated as before. But in the ma- 
jority of cases it is far otherwise. In three instances of this nature, 
which have come under my own observation, the tumors have disap- 
peared ; and the manner of their disappearance is worthy of remark. 



/194 TUxMORS OF THE UTERUS. 

In one instance, occurring two years since, the tumor was located in 
the posterior wall of the uterus, apparently in the central portion of 
it, and occupied the middle zone. The pregnancy proceeded without 
accident, and the patient was delivered at term of a dead foetus, w^hich, 
judging from appearance, must have been dead three days before 
labor came on. Moreover, according to the calculation of the mother, 
the first pains did not appear until two weeks after the expiration of 
two hundred and eighty days. The head was arrested at the superior 
strait and impinged upon the symphysis pubis, but was easily 
moved fcom this position. I did not see the patient until four hours 
after the membranes had been ruptured. At this time the presenting 
part did not advance; and, after consultation with the attending 
physician. Dr. John F. Williams, of this city, it was considered best 
to interfere. I introduced my hand, seized one of the feet and brought 
it down. There was no great difficulty in the turning or delivery. 
The placenta came away in a few minutes with a very slight loss of 
blood. I had first seen this patient when gestation had advanced to 
the end of the third month. At this time I believed the tumor to 
be about the size of a fetal head at terra. It was extremely hard, 
and presented two distinct nodules. At this consultation I advised 
non-interference. I saw her again several times during her preg- 
nancy. She was a primipara. After the delivery of the placenta I 
felt curious to know what effect the pregnancy had upon the size and 
consistency of the tumor. In order to determine these points I in- 
troduced one hand into the uterus, and with the other manipulated 
above the symphysis. In this way I could fix and handle the tumor 
with facility. It then seemed to be about the size of the fetal head 
and very hard. The division between the firmly contracted uterus 
and the tumor was marked by a well-defined sulcus, traceable by the 
hand, above the pelvic brim. The tumor seemed harder than the 
contracted uterus. I had the opportunity of seeing and examining 
this patient frequently during the year succeeding her accouchement. 
The tumor was decidedly less in three months, and continued to dis- 
appear. At the expiration of twelve months it was no longer per- 
ceptible, and the cavity of the uterus measured but two inches and a 
quarter. The patient now menstruates normally in every respect. 

The careful observation of this case convinced me that the tumor 
had not grown materially larger nor become softened during gesta- 
tion, and led me to believe that the process of absorption began and 
proceeded with the subsequent involution of the uterus. What effects 
may have been wrought upon its tissues by the contractions during 



PROGNOSIS. 



495 



labor I cannot of course determine ; but the gradual disappearance 
of the tumor and the non-appearance of inflammatory or other urgent 
symptoms plainly indicate that the contractions of the uterus during 
labor could not have produced any very violent effects upon it. It 
was also evident that the tumor was absorbed and slowly removed 
without disturbing the good health of the patient. 

In the other two cases I verified the existence of fibrous tumors 
before pregnancy took place, and one of them I saw again after a 
lapse of five months, but was not present at the time of parturition 
of either of them, nor have I seen them subsequently. I have been 
assured, however, by letters from their attending physicians, that 
they recognized the tumor after labor, and that they both disappeared 
within a year. 



CHAPTER XXXiy. 

FIBEOUS TUMOES OF THE UTEEUS, CONTINUED. 

Treatment. 

The treatment of fibrous tuDiors of the uterus consists largely of 
the means calculated to relieve such symptoms as endanger the life 
of the patient or materially aifect her general health. TMien these 
are unayailing, resort is had to measures calculated to get rid of the 
tumor. Some remedies necessary to the relief of symptoms act as 
very powerful curative agents ; hence, while it is convenient to speak 
of the treatment of symptoms under one division of the subject, and 
the methods employed for radical cure under another, we cannot, in 
fact, completely separate these two branches. The reader will not be 
surprised, therefore, if I feel myself obliged to depart from this arbi- 
trary method of presenting my subject. 

Haemorrhage is by far the most important of the symptoms con- 
nected with these growths, because it is at the same time the most 
frequent and hazardous. It is also the symptom that leads to most 
suffering in consequence of depriving important organs of the blood 
necessary to support them in their functions. Every means, there- 
fore, should be made use of not only to prevent fatal losses but also 
to prevent even slight haemorrhage. In the outset, therefore, I would 
insist upon watching with great vigilance to prevent any unusual loss 
of blood. It wnll be understood by this that I advise not to tem- 
porize by adopting the milder and less efficient measures as being 
sufficient for cases not likely to prove fatal, but to treat all hemor- 
rhage arising from this cause with promptitude and energy. Fortu- 
nately in many cases we can anticipate the attacks of haemorrhage 
because we know when they will recur, and we are generally able 
to judge of their probable severity. To discharge our doty in this 
respect effectually, our patient should be properly provided with 
remedies and fully instructed how to use them. She should be made 
to understand that unusual haemorrhage at the meubtrual period may 
be checked without endangering her general health. Among the 
remedies are, dorsal recumbency with the hips elevated, cold to the 
hypogastric region, and cold to the dorsal spine and sacrum, which 
can be effected by means of a rubber pillow filled with ice water, 



TREATMENT, 497 

ergot and some form of tampon. The best fluid extract of ergot in 
drachm doses, if the stomach will bear it, is probably the most effica- 
cious medicine, but the fresh drug in the form of infusion is also 
very efficient. Full doses should be given every half hour when 
there is much loss, until some effect is produced upon tlie haemor- 
rhage, and then continued every four hours as long as necessary. 
Compressed sponges saturated with the solution of alum make the 
best tampon for the patient to make use of. These may be made and 
kept in readiness, so that they can be introduced as soon as they are 
found necessary. The patient or nurse can make them by taking a 
fine sponge, large enough to fill the vagina, passing a ])iece of strong 
string through the centre to aid in its removal, and then, after dipping 
it in the solution, well winding it with twine from one end to the 
other, compressing it into as small a space as possible. The twine 
should so compress the sponge as to make it assume an elongated 
form. It should then be laid aside and permitted to dry. Several 
sponges should be thus prepared and dried. When necessary the 
twine may be unwound and the sponge introduced. Its size when 
in the dry condition will allow of an easy passage into the vagina, 
wdiere the moisture will cause it to expand, thus filling up and seal- 
ing the vagina so as to absolutely check the discharges. If the at- 
tending physician is present he may tampon the vagina with pellets 
of cotton secured by thread and moistened with the solution of iron, 
as recommended by Dr. Sims and others. The inconvenience ex- 
perienced from this ironized plug will be more than counterbalanced 
by the saving of blood. This form of tampon has the additional 
advantage of being antiseptic. I have allowed it to remain for three 
days, and upon removing it satisfied myself that there was no decom- 
position of the blood or the vaginal secretions. When the tampon 
is removed it will not be found difficult to wash out all the granular 
clots caused by its presence. It may be repeated as often as neces- 
sary, but usually if allowed to remain forty-eight hours the haemor- 
rhage will not return. It may be said that for small losses this is 
unnecessary, but I think this is a more convenient form of tampon 
than any other that will answer the purpose. In dangerous cases no 
one will question the propriety of its employment. 

Another very important means of arresting haemorrhage, which 
can be used by the physician when necessary, is the introduction of 
a compressed sponge into the cervix uteri for the purpose of dilating 
it. This will temporarily act as a tampon and stimulate the uterine 
fibres to contraction. A point of much importance in the use of the 

32 



498 FIBROUS TUMORS OF THE UTERUS. 

tampon or sponge, is the avoidance of septicsemic poison, and I know 
no medicine so efficacious and handy as th^ preparation of iron I have 
mentioned. 

The pressure of the tumor upon the pelvic viscera is another in- 
convenience which calls for attention. This takes place usually at a 
time when the tumor has acquired a size sufficient to fill that cavity. 
Consequently the elevation of the tumor above the pelvis is the 
remedy. This may be done sometimes by placing the patient in the 
knee-elbow position and opening the vagina by two fingers, and then 
pressing the growth upwards. The powerful influence of atmos- 
pheric pressure called to our aid, by the position and opening of the 
vagina, is a very material auxiliary in the process of elevation. If 
this is not sufficient, we may pass tlie fingers into the rectum and 
elevate the tumor. I once succeeded in this operation by using an 
ivory-headed cane in the rectum when the fingers failed to reach high 
enough. 

Dysmenorrhoea is another symptom of fibrous tumors, and some- 
times a very distressing one, which we are often called upon to re- 
lieve. It depends, no doubt, as I have before said, on the imprison- 
ment of blood in the uterine cavity, in consequence of the tortuosity 
of the canal causing the closure of some part of it. The remedy con- 
sists in dilating these narrow places. I know of nothing so well cal- 
culated to effect this object as the slippery elm tent. A tent of this 
material, long enough to reach the fundus uteri, and of sufficient size, 
moistened so as to render it very flexible, may be passed up through 
these tortuous places with great facility. If introduced as soon as 
the symptom begins to manifest itself, and allowed to remain an hour 
or two, the relief will be pretty certain. If used once a day, for four 
or five days before the attack, and three or four hours at a time, 
dysmenorrhoea may be generally avoided. 

When we broach the question of the permanent cure of these afl'ec- 
tions, we find that great difference of opinion exists among the mem- 
bers of the profession as to the value of medicines. One part, per- 
haps a majority, believe that no medicine has any direct effect upon 
them, and they ignore any means of permanent relief but surgical. 
There is, however, a respectable number of medical men who place 
great reliance upon the administration of certain medicines, and, if I 
am not mistaken, recent observation has added greatly to their num- 
ber. They do not, however, wholly agree as to the therapeutic pro- 
cesses that should be instituted, and consequently do not employ the 
same kind of medicines. Some gentlemen have more confidence in 



TREATMENT. 499 

what I will term the sorbefacient process of treatment. They endeavor 
to institute measures that will cause the absorbents to attack and 
remove the neoplasm in the same way that tumefactions caused by 
effusions are removed. This they do by friction, pressure, and the 
administration of the old-fashioned sorbefacient medicines. The most 
popular among these are the iodides, chlorides, and bromides of mer- 
cury, potassium, sodium, calcium, and ammonium. Reports may be 
found in books and our periodical medical literature of cures by several, 
if not all, of these articles and their combinations. The late Dr. W. L. 
Atlee, whose experience has been very extensive, had great confidence 
in the action of hydrochlorate of ammonia. He caused it to be ad- 
ministered internally, applied externally, and used as vaginal injec- 
tions. The iodide of potassium has long enjoyed a great reputation 
in causing the absorption of these and other forms of tumors. There 
is no professional fairness in assuming that the faith in these reme- 
dies, derived from the observation of their effects, or the promulga- 
tion of cures from the use of sorbefacient measures, are fallacious. 
Some of the men arrayed in favor of the opinion that cures may be 
effected by a patient, and long-continued administration of some one 
of the articles I have mentioned, stand high as men of honesty, accu- 
racy of observation, and faithfulness in their records ; and for one I 
give full credence to their statements. Yet I must also say that I 
have not witnessed the good results which I unhesitatingly believe 
others have seen from the sorbefacient treatment alone. 

Others who expect much from medicinal treatment look to 
that class of medicines which causes contraction of the unstriped 
muscular fibres as the most promising. With these medicines they 
expect to diminish the supply of blood to the tumor, by causing con- 
traction of the arterioles traversing their substance, and thus disturb- 
ing their nutrition to such a degree as to stop their growth, lessen or 
destroy their vitality, and so render them subject to the influence of 
the absorbents, whereby they may be removed. Some of the more 
energetic of these medicines, as ergot, for instance^ often affect these 
growths very promptly. 

I shall limit my remarks upon this class of medicines to what is 
known of the effects of ergot. 

As an introduction to what I have to say of ergot I submit the fol- 
lowing propositions : 1. When properly administered, ergot fre- 
quently very greatly ameliorates some of the troublesome and even 
dangerous symptoms of fibrous tumors of the uterus, e. ^., haemor- 
rhage and copious leucorrhoea. 2. It often arrests their growth and 



500 FIBROUS TUMORS OF THE UTERUS. 

checks hseraorrhage. 3. In many instances it causes the absorption 
of the tumor, occasionally without giving the patient any inconve- 
nience ; at other times the removal of the tumor by absorption is 
attended by painful contractions and tenderness of the uterus. 4. By 
inducing uterine contraction it causes the expulsion of the polypoid 
variety. 5. In the same way it causes the disruption and discharge 
of the submucous tumor. 

There are many cases on record to substantiate every one of these 
propositions. 

From what I consider well-authenticated sources, including the 
cases under my ow^n observation and in the practice of my friends 
and neighbors, I have collected one hundred and thirty-six cases of 
fibroid tumors treated by ergot. Of these, twenty-five cases were 
cured without giving the patient any inconvenience from painful con- 
tractions. In forty-six cases the tumors were diminished in size and 
the haemorrhage was cured. In twenty-seven others the haemorrhagic 
symptoms were relieved, while the size of the tumor was not affected. 
In eight other instances the tumors were broken to pieces and ex- 
pelled piecemeal. 

At the risk of being tedious I will copy the summary of cases and 
opinions reported to me and given in my address on obstetrics made 
before the American Medical Association in 1875 ; 



Cases. 

It is well known that Professor Hildebrandt, in a communication 
,to the twenty-fifth number of the Berliner Wdchenschrift, as early as 
1871 called the attention of the profession to the utility of ergotin 
in the treatment of fibrous tumors of the uterus. While administer- 
ing it by hypodermic injections to moderate the haemorrhages, so often 
a troublesome symptom in connection with these growths, he was 
struck with the decided diminution in the size of the tumor. A con- 
tinuation of the remedy thus administered resulted in the entire dis- 
appearance of one of them in fifteen weeks. In eight cases, all but 
two underwent great improvement. The great pain caused by injection 
rendered the treatment intolerable to one of these two patients. In 
the other the treatment was discontinued on account of ergotic in- 
toxication. In four others, the tumors were greatly diminished, and 
promised speedy cures, but for various reasons the treatment was not 
continued. One tumor of huge size, reaching above the umbilicus? 
totally disappeared; while another, extending to the ribs, and largely 



CASES. 5U1 

distending the abdomen, was greatly reduced. The debilitating 
haemorrhages and leucorrhoeal discharges were promptly relieved in 
six of them. 

In the American Journal of Obstetrics for January, 1875, Dr. 
Hildebrandt gives a synopsis of nineteen more cases treated by him. 
Two of these were cured; and in six others the tumors were greatly 
diminished in size, and the haemorrhages relieved. In eleven of these 
cases all the disagreeable symptoms were relieved, but the size of the 
tumor was not perceptibly affected. The last two cases reported in 
this series of nineteen were not benefited. 

Soon after Professor Hildebrandt made his first report of cases. Dr. 
Bengelsdorf read a paper upon the subject at a meeting of the Griefs- 
wald Medical Society. He alluded to four cases in which he had 
used the hypodermic injections of ergot. Two of these w^ere in pa- 
tients after the menopause ; neither of them seemed to be influenced 
by the treatment. In the other two the patients were menstruating 
and the subjects of severe metrorrhagia. This symptom in both cases 
was very much mitigated, but the tumors were not materially, if at 
all diminished in size. Treatment was interrupted in one of them 
after the administration of sixteen injections. Dr. Bengelsdorf was 
favorably impressed by the treatment. 

Dr. Chrobak, of Vienna, reports, in the seventh volume, second 
number, of the Archives fitr GyncECologie, nine cases. In the first, 
the tumor the sizef of a small apple was partially expelled from the 
cavity of the body into the cervical canal ; the mouth of the uterus 
was dilated by sponge, and the protruding segment removed with the 
scissors. In case second, after forty-three injections, the tumor, 
which was situated in the posterior wall of the uterus, was not re- 
duced in size, but the haemorrhage was cured. The tumor in case 
third consisted of several nodules in the anterior wall of the uterus ; 
after twenty-four injections, there was no diminution in size, but the 
haemorrhage was cured. In case fourth the tumor was situated in 
the posterior wall and reached up to the umbilicus ; after three in- 
jections the treatment was discontinued on account of the pain and 
inflammation caused by them. In the fifth case the amount of haem- 
orrhage was reduced, but the treatment was discontinued for the 
same reason as in case fourth. The tumor in case sixth was large, 
the uterus rising above the umbilicus; after twelve injections with- 
out results, the patient could not be induced to receive further treat- 
ment. The seventh patient was fifty-seven years old, and the tumor 
showed a multitudinous development; the second injection, which 



502 FIBROUS TUMORS OF THE UTERUS. 

was administered eight days after the first, caused severe symptoms 
of collapse, and the treatment was discontinued. The tumor in the 
eighth case was in the anterior wall of the uterus and reached above 
the umbilicus, and the monthly flow continued from eight to ten 
days ; seven injections were used, with diminution of the tumor and 
improvement in the hsemorrhages ; the treatment in this case he ex- 
pected to continue at some future time. In the ninth case the uterus 
was anteverted, and the cavity measured four and three-fourths 
inches in length ; after twelve injections the haemorrhages ceased and 
the tumor diminished in size ; the uterine cavity measuring only three 
and one-third inches in length. 

Dr. Lombe Atthill records three cases in the Irish Hospital Ga- 
zette for September 1st, 1874. The first case was benefited in the 
diminution of the flow and the improvement of health. The second 
case was under treatment but a very short time ; only five injections 
were administered, when the patient refused to permit another be- 
cause of the severe inflammation following them. The third case was 
benefited, but abandoned from the same cause. 

Dr. J. P. White, of Buffalo, IS". Y., writes me that he believes it is 
in this direction — the use of ergot — we must look for relief in the 
intramural and non-pediculated varieties of uterine fibroids. He says 
that in the last year and a half he has resorted to ergot in these vari- 
eties with marked benefit. In a few instances they have been com- 
pletely absorbed, and in a larger number the growth of them was 
arrested, the tumors were diminished in size, and the haemorrhages 
were suspended. He says that the number of his cases is fourteen, 
and that not more than one-third can be called cured, while in almost 
the same proportion, the growth has been stayed or diminished, and 
the bleeding arrested. 

Dr. E. W. Jenks, of Detroit, Michigan, now of Chicago, in a re- 
cent letter, says he has used ergot during the past two years in the 
treatment of fibroid tumors of the uterus with the most gratifying 
results. Seventy-five per cent, of all cases thus treated were bene- 
fited, as manifested by arrest of growth and control of haemorrhage. 
About ten per cent, of the patients he considered cured. 

Dr. H. C. Howard, of Champaign, 111., sends me an account of two 
cases treated by him. The first case was in an unmarried woman. 
The tumor was one originating from a single nucleus, intramural, 
and as large as a pint measure. He administered hypodermic injec- 
tions of ergotin for some weeks, and afterward continued treatment 
for eight months by administering internally the fluid extract of ergot 



CASES. 503 

and belladonna. This case, he says, was entirely cured by his treat 
ment. His second case was in the person of a married woman, forty 
years of age, and the mother of two children. When first seen by 
him she had been the subject of severe floodings for three years. He 
found, upon examination, a submucous fibroid as large as a quart 
cup. He used large quantities of ergot by vaginal injections and by 
the mouth for four months, at which time the tumor had entirely 
disappeared. 

Dr. A. Reeves Jackson reported to the Chicago Society of Physi- 
cians and Surgeons, April 13th, 1874, five cases of fibrous tumors of 
the uterus treated by hypodermic injections of the solution of the 
solid extract of ergot. The tumors in four of these cases were intra- 
mural ; in the fifth the tumor was subperitoneal. The tumor in one 
was entirely cured ; in two others the tumors were greatly diminished 
in size. In another the tumor seemed unaffected, but the profuse 
haemorrhages from which the patient suffered were diminished in 
frequency and profuseness. The fifth, a subperitoneal tumor, was 
not benefited. 

Dr. Jackson reports to me three other cases. One was in a colored 
woman ; the uterus reached to the umbilicus ; it was entirely cured 
in three months. In the second the tumor reached above the um- 
bilicus ; this was temporarily reduced in size by the ergot, but, after 
treatment was abandoned, it regained its former dimensions. The 
treatment was discontinued by the patient because of the distressing 
pain and contractions which occurred after eight weeks' use. The 
profuse uterine haemorrhage was checked, and health improved. 

At the same meeting of the Society of Physicians and Surgeons 
at which Dr. Jackson's first five cases were reported. Dr. Etheridge 
reported one case entirely cured. His diagnosis was confirmed by 
Drs. Gunn and Miller, Dr. Etheridge's associate professors in Rush 
Medical College. Dr. Fisher also reported an intramural fibrous 
tumor cured in six weeks. I saw this case, and have no doubt of 
the correctness of Dr. Fisher's diagnosis. 

On the same occasion Dr. Merriman, one of my colleagues, re- 
ported three cases ; one, intramural, in the anterior wall, cured ; one, 
subperitoneal, pediculated ; the health of this patient Was much im- 
proved, and the growth of the tumor checked ; the patient was still 
under treatment. The tumor in the third was intramural. At the 
time of reporting, the size was gradually diminishing. 

Dr. John Morris, of Baltimore, Md., communicates to me a case 
that seemed to be decidedly benefited by the ergot treatment; but. 



504 FIBROUS TUMORS OF THE UTERUS. 

on account of the violent uterine contractions produced by the remedy, 
the patient would not consent to continue the treatment. 

Dr. Charles E. Buckingham, of Boston, Mass., has tried hypo- 
dermic injections of ergot in the treatment of fibrous tumors of the 
uterus in but one case. The result was entirely negative. 

Dr. George Cowan, of Danville, Ky., reports a case in the person 
of a colored woman, unmarried, and about forty years of age. The 
hypodermic injections of ergotin were used for two weeks. At the 
end of this time the greatest circumference of the abdomen was re- 
duced from thirty-six inches, which it measured before the treatment 
was instituted, to twenty-eight and one-half inches. The patient, 
returning home, used the injections herself. Such frequent and pain- 
ful abscesses ensued, however, that she discontinued them. During 
the use of the injections an obstinate constipation was removed, and 
her general health much improved. The abandonment of the treat- 
ment was followed by a return of the constipation, loss of flesh, great 
debility, and the abdomen increased in size until it measured thirty- 
two inches. A return to the treatment was followed by the same 
marked improvement in the general health, and a reduction of the 
size of the abdomen to twenty-seven and one-fourth inches. 

Dr. H. W. Dean, of Rochester, X. Y., sends me an account of two 
cases treated by him. The first case was that of a patient, forty- 
seven years of age, the mother of three children, the age of the 
youngest nineteen. She suffered from pressure upon the bladder and 
rectum, and Avas the subject of severe menorrhagia. The tumor 
extended two inches above the umbilicus, and occupied the lower 
half of the right lumbar, the whole of the right inguinal, and fully 
half of the corresponding left abdominal regions. The os uteri was 
a little to the left of its natural position, and sufficiently open to 
admit the finger half an inch. An elastic catheter was introduced 
into the uterine cavity between seven and a half and seven and three- 
fourth inches. The diagnosis was interstitial fibrous tumor of the 
uterus. Intrauterine injections, through the elastic catheter, of half 
a drachm of Squibb's fluid extract of ergot, were made four times 
during each menstrual interval, from April until October, 1874. 
Injections into the substance of the cervix were made with the same 
frequency from October to the middle of December. The results 
were, reduction in the size of the tumor until the upper margin sank 
two inches below the umbilicus, and the uterine cavity measured only 
four and a half inches. 

The second case was that of a woman, forty-eight years of age, the 



CASES. 505 

mother of three children, the voung^est of whom was sixteen. She 
flowed irregularly, the intervals varying from one to three weeks. 
The flow was profuse and attended with great pain. In the inter- 
vals there was a copious flow of serous leucorrhoea. She also suffered 
from pressure upon the bladder and frequent micturition. The tumor 
occupied the right side of the abdomen, extending nearly to the um- 
bilicus, and to midway between the linea alba and the left ilium. 
The vagina could not be satisfactorily explored until the hand was 
introduced. When this was effected the finger could be easily passed 
into the uterus. Between the finger thus introduced and the hand 
on the hypogastric region, the presence of an interstitial fibrous 
tumor was diagnosticated. A flexible catheter was passed into the 
uterine cavity to the extent of eight inches. Injection into the sub- 
stance of the cervix was followed in fifteen minutes by continuous 
uterine contractions, which lasted twenty-four hours. This injection 
was repeated four times a month. When the amount was increased 
from fifteen to twenty minims, great gastric and cerebral disturbance, 
together with intense cutaneous engorgement and uterine pain, en- 
sued. The injections were continued from Xovember, 1873, to the 
middle of the year 1874. At this time the upper margin of the 
tumor was but one inch above the symphysis pubis, and the cavity 
of the uterus measured four and a half inches. Menstruation was 
quite normal as to time and quantily, and attended with little pain. 
The pelvic organs were not subject to disagreeable pressure. 

Dr. W. C. Wey, of Elmira, X. Y., in a lengthy and interesting 
letter, gives me the results of his treatment in one case. The patient 
was forty-seven years old. The bulk of the tumor was equal to both 
closed hands. It was reduced in six weeks about one-third, and in 
six months to one-half of its original size. The patient, before the 
treatment, was very much reduced ; her extremities had become 
(Edematous, and exercise was almost impossible from the effects of 
haemorrhage, which had become almost constant. These symptoms 
were relieved with great promptitude and in four months the menses 
had become normal in every respect. His treatment was continued 
twenty-seven months, but most of the good results, if not all, were 
obtained in the first six months. 

Dr. Edward M. Hodder, of Toronto, writes me that the number of 
cases in his notebook, since May, 1873, is twenty-five; but all of 
these reside at a distance, and therefore he saw or heard of them only 
occasionally. Xearly the whole of them were treated witli ergot, but 
not exclusively, as he combined with it the bromide and iodide of 



606 FIBROUS TUMORS OF THE UTERUS. 

potassium. In the majority of the cases, treatment appeared to arrest 
further growth, and after a time caused the tumors to diminish in 
size. In a few cases the tumors disappeared entirely. He gives four 
cases in minutiae : in one case the treatment was commenced May, 
1873; the tumor nearly disappeared, and the patient is now six or 
seven months advanced in pregnancy. In the second case, the treat- 
ment was begun in June, 1873; the tumor was greatly diminished 
in size, the patient became pregnant, and was delivered late last 
autumn. In the third case the treatment was commenced in Sep- 
tember, 1873; the tumor disappeared, and the patient is now preg- 
nant. In the fourth case treatment was commenced in September, 
1873, and the tumor is now nearly gone, and the patient feels quite 
well. 

Through the kindness of Dr. Hodder I have received the report 
of another case by Dr. Jukes, of St. Catherines. The tumor was 
discovered by Dr. Jukes at the time of delivery after a normal preg- 
nancy. The history of the case shows that its existence had been 
recognized by Dr. Hodder before the patient was married. Dr. 
Jukes gave the fluid extract of ergot continuously to this patient for 
three months, first in doses of one-half drachm, and afterwards in- 
creased the dose to one drachm, combined with the various prepara- 
tions of iodine. From the beginning, the tumor slowly decreased in 
size, and at the end of three months had entirely disappeared. Some 
weeks after delivery, he passed the sound into the uterine cavity six 
inches, and the organ reached very nearly to the umbilicus. After 
the three months' treatment the measurement by the sound showed 
the organ to be very slightly above its normal size. 

Dr. Strange, of Aurora, Canada, says that he had on several occa- 
sions given ergot internally to arrest the haemorrhage attendant upon 
fibrous growths in the uterus, and had observed that it tended to re- 
tard their further growth. 

Dr. L. F. Warner, of Boston, has used ergot in two cases of fibrous 
tumors of the uterus, but could perceive no beneficial effects. 

Dr. J. H. Thompson, Surgeon in Chief of the Columbia Hospital 
for Women and Children, reports three cases treated by ergot, in 
all of which the tumors were reduced in size, the metrorrhagia cured, 
and the general health, which in all was much impaired, was entirely 
restored. In one of these cases Dr. Thompson injected the ergot into 
the substance of the tumor by passing this instrument through the 
cervical cavity, and thence penetrating the growth. No unpleasant 
effects followed this method of using the remedy. 



CASES. 507 

Dr. Riissel, of Oshkosh, AYisconsin, reports one case in which the 
tumor of large size was very much reduced, and all the disagreeable 
symptoms were removed. 

During the year since the last meeting of the Association I have 
treated seven cases. 

One was not affected by the ergot, and the patient died six weeks 
after the commencement of the treatment. She was anaemic to a de- 
gree wdiich I have seldom before seen. The remedy was adminis- 
tered hypodermically every day, thirty drops of Squibb's solution of 
the solid extract being injected each time. 

The second patient "was the subject of a uninuclear tumor, situated 
in the anterior wall of the uterus, about the size of the fetal head. 
She had profuse haemorrhages at her menstrual periods, and copious 
leucorrhoeal discharges between them, and had become very ausemic. 
The discharge ceased and the tumor disappeared in five months from 
the time she first came under my care. The remedy was at first 
used hypodermically ; but, on account of the pain and inflammation 
at the punctures, I was obliged to cease this mode of administering 
it, and gave it internally. Teaspoonful doses of Squibb's fluid ex- 
tract were given twice a day for the last three months of the time 
the patient was under treatment. 

In three other cases, in which the medicine was given internally, 
the tumors were very much reduced in size, but did not disappear. 
The haemorrhages and leucorrhoea were cured, and the patients re- 
stored to health. 

In another, the haemorrhages and leucorrhoea were rendered much 
less profuse, but the tumor was not reduced in size. 

In a colored senile patient, over sixty years of age, with a large 
multiple tumor, no effect was produced by the ergot. 

In four of my cases I w^as obliged to suspend the treatment several 
times for a few days, to give the patients a respite from the almost 
constant pain. 

Five of these complained of great heat and tenderness of the uterus 
after they had been under treatment about four weeks. 

In all, the pulse was accelerated and remained small and weak. 

As one of my cases presented some features of more than ordinary 
interest, I will give it more in detail : The patient had been married 
twelve years, was thirty-seven years old, and sterile. She had been 
aware of the existence of the tumor for three years, but could not 
give a very clear history of its progressive enlargement. The uterus 
extended three inches above the pubes, and was a little to the right of 



508 FIBROUS TUMORS OF THE UTERUS. 

the median line, very hard, and irregular in shape; but I could not 
discover that there were subperitoneal nodules. Per vaginam, the 
tumor could be felt to occupy the right side and anterior wall of the 
uterus, and fill up two-thirds of the pelvic cavity. The cavity of 
the uterus measured four and a quarter inches. A polypus, pyriform 
in shape, quite firm in consistence, about the size of a pigeon's egg, 
depended from the mouth of the uterus, and appeared to be attached 
to the upper part of the posterior wall of the cervix. The diagnosis 
was intramural fibrous tumor of the uterus, with two nuclei of de- 
velopment, and a fibrous polypus. The patient was somewhat anae- 
mic from the long continuance of profuse leucorrhoea and metror- 
rhagia. Without removing the polypus, I commenced treatment by 
giving the patient three grains of the solid extract of ergot three times 
a day. The next menstrual flow was not so profuse, and the leucor- 
rhoea diminished almost from the beginning. At the end of four 
months the menstruation was normal, the leucorrhoea had ceased, the 
tumor was reduced to half its former dimensions, and the patient's 
health restored. A continuation of the treatment two months longer 
causing no further reduction of the tumor, it was suspended. During 
the treatment, I w^atched with much interest the effects produced 
upon the polypus, examining it once in every ten or twelve days. It 
showed decided decrease in size at the end of the first ten days, and 
progressively decreased until, at the expiration of four months, it was 
not more than one-third the size it presented when first examined. 
It was twisted off at this time with great ease, and its removal was 
followed by almost no loss of blood. 

The most remarkable case of which I have any knowledge was 
reported to me by Dr. G. C. Goodrich, of Minneapolis, in which 
absorption of a large tumor took place under the administration of 
ergot and belladonna. I subjoin his description: 

"The treatment was commenced in 1870, and continued two years. 
The uterus filled the whole space between the ilia, and measured in the 
transverse diameter twelve inches, and in the vertical nineteen inches, 
extended up under the ensiform cartilage and close up to the margin of 
the cartilages of the ribs. The treatment was followed by cramps in the 
uterus, which produced a wild enthusiasm in the mind of the patient, 
and inspired her with strong hopes of recovery. Without consulting me, 
she doubled the dose of medicine, which was administered internally, 
and as a consequence she was attacked with very strong uterine contrac- 
tions and symptoms of metritis. This caused me to abandon treatment 
for about one month, and had it not been for the urgent determination 



CASES. 609 

of the patient, I would not have resumed it. She insisted that as this 
was the first medicine which had ever affected the enlarged organ, she 
believed it would cure her, and promised to obey my directions if I 
•would proceed. She so promptly and rapidly improved that I doubted 
if it were not a coincidence with, rather than a consequence of, the treat- 
ment. Prompted by this doubt, I abandoned the use of the ergot and 
belladonna and continued alterative treatment. The patient soon as- 
sured me that she no longer felt the griping pains caused by the remedy, 
and that the tumor was softer and larger than when she took the ergot 
prescription. The ergot and belladonna were again resumed, and in four 
months she was able to make a trip to Boston alone. While absent, she 
continued to take the medicine. From this time she continued rapidly 
convalescing, and is now in the enjoyment of fine health."* 

I subjoin cases in which the tumors were expelled piecemeal under 
the administration of ergot which came under my own observation : 

The first case in Avhich this process was attained occurred in the 
practice of Dr. H. P. Merriman. So far as I am aware it is the first 
case on record. With several other medical gentlemen I had the 
opportunity of seeing the patient several times, fully verifying the 
diagnosis, and witnessing the results of the treatment. 

It was recorded in my address before the American Medical As- 
sociation already referred to. Dr. Merriman says : 

"Mrs. K., aged thirty, the mother of three children, came to me in 
September, 1874, in regard to a tumor in the abdomen. Examination 
revealed a large tumor about the size of a four and a half months' 
pregnancy ; it was found to be interstitial, and situated on the right side 
and a little anterior; the sound passed six and three-fourths inches. She 
was at once given twenty drops of fluid extract of ergot (Squibb's) three 
times a day. She came a month later saying she was much better in 
health, but the tnmor remained the same. I told her to continue the 
medicine, but to increase the dose to twenty-five drops and after a time 
to thirty. I have seen her three or four times during the past winter, 
and twice had to suspend treatment and give opium on account of severe 
pain and tenderness in the uterine region. Finally, March 23d, 1875, I 
stopped all use of ergot, as the patient was very weak, the pulse 110, the 
appetite poor, and a very offensive and abundant discharge was coming 
from the uterus. The os uteri was very patulous. On April 5th, I was 
summoned in great haste. Something had just come away from the pa- 
tient. I found it to be an offensive fleshy mass, evidently a disintegrated 
fibrous tumor. Examination showed no tumor in the abdomen, but 

* The author's address before the American Medical Association at its meeting 
in 1875. 



510 FIBROUS TUMORS OF THE UTERUS. 

per vaginam the os patulous, soft, and very sensitive, and the uterus still 
large. A week later the uterus had regained its normal condition." 

As an evidence of the complete restoration of the health of the pa-^ 
tient, Dr. Merriman informs me that she has since had a fine healthy 
child. 

The next case, which has never been published, occurred in my 
own practice, and I will give a brief account of it : Mrs. W., forty 
years of age, had been married eighteen years, and had not borne 
children or been pregnant. She had enjoyed good health and noticed 
nothing unusual in her menses until about three years before she con- 
sulted me on July 17th, 1875. Three years ago she began to have 
an increased menstrual flow, the intervals were shorter, and she be- 
came the subject of an acrid leucorrhoeal discharge. For the last 
seven or eight months the flow has been almost constant, but moder- 
ate. The catamenial periods had been during the time well marked 
by a profuse discharge every four weeks. She was quite feeble from 
the great loss of blood she had sustained, very nervous and dispirited. 
For more than a year she had been conscious of the presence of a 
tumor in the hypogastric region. She had at no time observed that 
the discharge was fetid, or indeed had any smell. By palpation, a 
tumor could be found extending to within about two inches of the 
umbilicus, and filling up the same space in the lower part of the ab- 
domen which the uterus occupies at five months' pregnancy. It was 
globular, very hard, somewhat nodulated in shape, and movable. 
The cervix, when examined per vaginam, was ascertained to be long 
and pointed, and the rnouth small, and not at all patulous. The 
probe entered the uterine cavity, passing upward and backward fully 
four inches, and moved with the impressions made upon the tumor 
above the symphysis. 

From the history and examination it was not difficult to diagnose 
a fibrous tumor in the anterior wall of the uterus. 

I prescribed thirty drops of the fluid extract of ergot three times 
a day, to be taken in a wineglassful of water, and large injections 
of cold water twice a day. 

On July 19th the patient called to see me again. She informed 
me that the medicine had caused great pain in the tumor, resembling 
cram23S, with a strong desire to bear down, as though something was 
coming out of her. An examination revealed no change in the size 
of the tumor, but increased hardness and irresrularitv of its surface. 
She was directed to continue the medicine. On the 25th the patient 
complained that the pains were almost unendurable on account of 



CASES. 511 

their sev^erity and continiiousness. She said they prevented her from 
sleeping, or resting in any position. For the two days previons to 
her call on the 25th she had noticed in the discharges — which were 
less bloody — stringy and lumpy substances. This was different from 
anything she had seen before. Still there was no fetor. The tumor 
seemed to be somewdiat less in size than upon the first examination. 
There were some changes in the cervix ; it was soft, and the mouth 
was patulous ; the finger entered it a short distance, but would not 
pass the inner os uteri. The cervix was still as long as before the 
commencement of the pains, and I thought the lower portion of the 
tumor seemed more elastic than at first. 

On the 27th the pain was so severe and persistent that I thought 
it advisable to diminish the doses of ergot, and directed her to take 
only fifteen drops three times a day. The discharge ^vas increasing 
in quantity, and she gave me several pieces, one of which was as 
large as a cherry. It w^as so firm that it was difficult to break it up 
with the fingers, and of grayish color. There was no odor that I 
could discover in the piece examined. 

Dr. AV. H. Warn was kind enough to examine this specimen with 
the microscope. He found it composed mostly of hypertrophied con- 
nective tissue fibres, with bloodvessels running parallel to them. The 
tumor had decidedly decreased in size. 

On July 31st the pains, with less severity, were still continuous 
for the greater part of the day and night. There was a constant dis- 
charge of these small fibrous lumps. Judging from a close exami- 
nation, the tumor was not half so large as when first seen. 

The discharge continued without diminution until the 15th of 
August, when it became less, and the pain also decreased. At this 
time the upper part of the tumor could barely be felt above the sym- 
physis. The cervix was still long, but the mouth was less patulous, 
and the probe would not pass more than two and a half inches. 

Since the commencement of treatment the bloody discharge has 
not indicated a menstrual flow. In fact, the bloody discharge be- 
came progressively less, until it had entirely ceased about the middle 
of August. 

The patient^s health greatly improved, and she was permitted to 
return to her home in the country. She wrote me on the 1st of 
September that she still sufi^ered pain, and the discharge still con- 
tinued, but that it now had the appearance of pus, and was somewhat 
fetid for the first time. In October she wrote me again to say that 
there was no sign of the tumor; she had no pain, and never enjoyed 



512 FIBROUS TUMORS OF THE UTERUS. 

better health. She had menstruated twice since she had returned 
home, but the discharge at both periods was moderate, and she had 
no pain. She continued the ergot up to the middle of September. 

Mrs. Arthur King, of Sterling, Illinois, called on me December 
13th, 1875. She was thirty-five years old, married, and had never 
been pregnant. 

On the 1st of the preceding June she noticed a circumscribed hard 
lump two inches below and to the left of the umbilicus. She was 
the subject of serious uterine and sympathetic symptoms, for which 
she had at different times had treatment. She had profuse menor- 
rhagia, leucorrhoea, and great sense of weight in the pelvis. 

Upon examination I found a hard, round, movable tumor, extend- 
ing up to within two inches of the umbilicus, filling up the whole of 
the right iliac, the hypogastric, lower half of the umbilical, and more 
than half of the left iliac regions. 

The contour of the tumor was somewhat uneven, though not dis- 
tinctly nodular. The cervix was long, pointed, and thrown backward 
and to the left. The sound entered the small uterine mouth and 
passed upward, backward, and to the left five and a half inches. 

The diagnosis was a fibrous tumor of the right anterior wall of the 
uterus. I prescribed thirty drops of Squibb's fluid extract of ergot 
to be taken three times a day. She went home, but did not com- 
mence taking the medicine until the 20th of December. On the 26th 
of December Dr. J. B. Crandall was called to see her, and describes 
her condition as follows: 

"The patient was in a state of great nervous prostration, and worn 
out by severe pain and loss of sleep. The pains commenced soon after 
taking the second dose of ergot, and were excruciatingly severe for about 
three hours, after which they continued less severely for two days and 
nights. She had more or less haemorrhage from the uterus after taking 
the ergot. Her pulse was feeble, 110 to 120 to the minute. The skin 
was hot and dry, and she complained of great pain and tenderness over 
the uterus and lower bowels. The feet were drawn up, and the face 
wore a pinched and peculiar expression." 

Under these circumstances the doctor administered anodynes, tonics, 
and nourishment, to the great relief of the patient. 

On January 11th, 1876, the patient began to pass from the vagina 
small masses of fibrous substance, from the size of a chestnut to that 
of an English walnut. The substances thus discharged* were firm 
and gray in color, and were exceedingly fetid. This discharge con- 



CASES. 513 

tinned up to the 21st of January, when the uterus was very much 
diminished in size, the tenderness had subsided, and the patient ap- 
peared comparatively comfortable. Up to that time she had taken 
but three doses of ergot, on the 20th of the preceding month, and the 
doctor ordered it to be resumed again. This time the ergot produced 
no pain, and after three or four days was discontinued. From the 
21st of January there ^vere no more pieces discharged, but up to 
February 1st a yellowish, thin, offensive fluid passed from the vagina 
in considerable quantities. On the first day of February the ergot 
was again ordered and continued two weeks, when, as no results 
ensued, it was finally dropped. 

Dr. Crandall states that on the 14th of February the uterus was 
reduced to its normal size, and on the 26tli the patient was up and 
about her work, completely cured. He remarked, in this connection, 
that the first three doses of ergot taken by the patient was the cause 
of her recovery. 

This case is published in the August (1875) number of the Chicago 
Medical Journal and Examiner, as reported by Dr. Crandall. 

Mrs. L. D. M., aged forty -seven years, had a fibroid tumor in the 
anterior w^all of the uterus, which, with the enlarged uterus, arose to 
within two inches of the umbilicus. 

She commenced taking thirty drops of the fluid extract of ergot 
on the 22d of September, 1876, and was to increase gradually the 
dose with the object in view of causing the disruption and expulsion 
of the tumor. The ergot at first produced no perceptible effect until 
she had taken it ten days, when she began to experience the pain of 
contraction. The pain became so severe and continuous that it w^as 
necessary to omit it for two or three days at a time. The patient 
was intelligent and understood the object and mode of action of the 
ergot, and when the pain entirely subsided, she courageously resumed 
it in the smaller doses, and increased again until the pains became 
intolerable. On the 13th of January, 1877, small pieces of the tumor 
showed themselves in the vaginal discharges, and by the 26th of the 
same month the whole of it had been discharged piecemeal. 

She wrote me on the 30th of January, saying : 

"I think I wrote one week ago to-day. At that time the tumor was 
passing. It continued to pass until the 26th, when, I think, the last 
was expelled. To-day I send you by express a portion of the last that 
came. I think the whole of it, including the portion I sent you, would 
have weighed one and a half pounds. I do not believe a quart can 
would hold it if the whole had been preserved. It commenced to come 

33 



514 FIBROUS TUMORS OF THE UTERUS. 

on Saturday, and from Saturday evening to Sunday morning there was 
a pint or more. After that, the stench was so disagreeable that we could 
not cleanse it, consequently we threw it away. Wednesday and Thurs- 
day it seemed to be in one continuous mass. I cannot better describe it 
than to say that it came like sausage-meat from a stuffer. I would cut 
off about four inches a day, that is on Wednesday and Thursday. On 
Friday morning the last of it came away." 

During, and for some days after, the expulsion she suffered slight 
symptoms of septicaemia, but recovered from them, and in the course 
of a month afterward she visited me, when I found the uterus meas- 
ured two inches and a half in depth. She then had some leucorrhoea, 
but was fast regaining her health. She is now perfectly well, and 
has passed in safety the menopause.* 

The following case is reported to me by letter by William Fox, 
M.D., of Milwaukee, January 19th, 1880: 

" Mrs. B., aged forty-three ; last child four years old ; did not get up 
well. Menstruation returned earlier than usual, and gradually became 
more frequent and profuse, and of longer duration. Finally the abdo- 
men began to enlarge so much that her friends believed her pregnant. 
But her health began to fail ; her losses became greater, and almost con- 
tinuous. She w^as without treatment, as she believed her condition due 
to her time of life. An examination revealed a uterus as large as at the 
sixth month of gestation, and could be easily felt and moved through 
the abdominak walls. A sound entered five and a half inches, and with 
it in the uterus and the hand outside, a tumor could be felt in the anterior 
wall. The patient was put upon 30-drop doses of Squibb's extract of 
ergot, four times daily, and sent to consult Dr. Byford February 3d, 
who confirmed the diagnosis and approved the treatment, and made a 
prognosis more favorable than I believed. He said, with the above treat- 
ment we would starve the growth, and possibly expel it. The period was 
detained a week, when it came on, February 21st, five weeks from the 
commencement of treatment, with a great deal of pain. The ergot was 
continued, the pain increasing, until, on the third day, I found the 
patient with a temperature of 105° ; pulse, 140, an offensive discharge, 
and complaining of a feeling as of some foreign body in the vagina. The 
vagina was full of a stinking mass, not unlike a placenta in feel, but 
harder. The os was quite open, and the fingers could readily pass into 
the uterus and describe the growth. All the gangrenous mass was taken 
away as fast as possible with the fingers and forceps, and the uterus care- 
fully washed out with carbolized hot water every four hours. The ergot 

■^ This case, the abstract of which I have here given, was in the May 15th, 1877, 
number of the Archives of Clinical Surgery, N. Y. 



SUMMARY OP CASES CURED BY ABSORPTION. 515 

was discontinued because of the pain. Whiskey, quinine, and milk con- 
stituted the treatment. She rapidly improved, and in less than a month 
was out driving, walking, and feeling well. In six weeks, menstruation 
returned ; came on without warning ; lasted less than three days ; the 
first natural period she remembers having had in four years. She has 
had three since, perfectly natural in every way. She is perfectly well." 

I have known ten cases in which the tumors were expelled piece- 
meal by ergot, with but one death. The death occurred in a patient 
who rode one hundred and fifty miles on a railroad train to see me, 
with pieces of the tumor hanging from the vagina, which she would 
not allow her physician to remove. When she arrived, I passed my 
fingers up into the contracted capsule and scooped out the remaining 
portion of the tumor. She was so exhausted, however, by the journey 
and the sepsis, that she died three days afterwards. 

I cannot help believing that if she had remained at home and 
submitted to the treatment of her physician, her life need not have 
been sacrificed. 

Summary of Cases cured by Absorption. 

The total number of cases here cited is one hundred and one. 
Twenty-two of them are reported cured. In thirty-nine more the 
tumors were diminished in size, and the haemorrhage and other dis- 
agreeable symptoms removed. Nineteen of the remainder were 
benefited by the relief of the haemorrhages and leucorrhoeal discharges, 
while the size and other conditions of the tumors were unchanged. 
Out of the whole number only twenty-one cases entirely resisted the 
treatment. This shows results decidedly favorable in eighty of the 
one hundred and one cases. 

We may still further appreciate the favorable effects of the treat- 
ment by the consideration that in twenty-one cases it was suspended, 
which is as great a number as resisted treatment. 

It is also a noticeable fact that some of the cases in which the 
treatment was suspended were very much benefited by it. 

I have no doubt that many more cases of fibrous tumors of the 
uterus treated by ergot might have been collected, had time per- 
mitted, as I have heard of cases the history of which I could not 
obtain. 

In collating my cases, I have in no way selected or arranged them 
to influence inferences as to results, but I have faithfully recorded 
all I have received from correspondents, or found in journals, which 



516 



FIBROUS TUMORS OF THE UTERUS. 



were given sufficiently in detail to enable me to arrive at a correct 
idea of the treatment and its effect. 



S N G rf 



pii 



Hildebrandt, 
Beno^elsdorf, . 

Chrobak, . . 

Atthill, . . 

White, . . . 
Goodrich, 

Howard, . . 

Jackson, . . 
Etheridge, 

Merriman, . 

Fisher, . . 

Morris, . . 
Buckingham, 

Cowan, . . 

Dean, . . . 

Wey, . . . 

Hodder, . . 

Jukes, . . . 

Warner, . . 

Bvford, . . 

Allen, . . . 

Thomson, . . 

Kussell, . . 



3 

14 

1 

2 
8 
1 
4 
1 
1 
1 
1 
2 
1 
4 
1 
2 
9 
1 
3 
1 



Total, 



101 



11 
2 
5 

3 

2 
1 

'i' 

2 
1 
3 



39 



19 



21 



i 



Modes of using Ergot. 

Not much uniformity has been observ^ed by the writers above 
quoted in the manner of using ergot. 

Drs. Hildebrandt, Bengelsdorf, Chrobak, Atthill, and Jackson 
recommend, and use it hypodermically. 

Drs. White, Jenks, and Howard administer it hypodermically, 
internally by the stomach, and in the form of suppositories in the 
vagina and rectum. 

Some of the arguments in favor of the hypodermic injections are : 
1st. It acts more rapidly and with more certainty. 2d. It does not 
produce the gastric disturbances sometimes caused by ergot when 
taken internally. 3d. It can be administered in this way when it is 
entirely impracticable to give it internally on account of the great 
exhaustion or gastric irritability of a patient. 

The main objections to the hypodermic method seem to be : 1st, 



MODES OF USING ERGOT. 517 

the pain inflicted by the needle; and, 2d, the inflammation and sup- 
puration which ensue. 

Dr. Hildebrandt has met with but one case where the pain of the 
puncture was an objection to its hypodermic use. With regard to 
abscesses he says : ^' I am sure I do not exaggerate when I say that 
up to the present time I have myself made one thousand hypodermic 
injections of ergotine for various purposes, or have seen them made 
and observed their results in the clinical wards in charge of my 
assistants." And he then adds: ^^I have never seen an abscess 
follow the injections made by me personally, and only in three clinical 
cases did this occur. The chief reason why no abscesses formed 
among the large number of other injections is that I always injected 
the fluid very deep into the subcutaneous cellular tissue — perhaps 
even into the abdominal muscles." 

Dr. Atthill met with this difficulty in all three of his cases, 
although he also injects the fluid deep into the tissues. 

Dr. Chrobak was obliged to desist from treatment on this account, 
in four out of his nine cases. 

Dr. Cowan was interrupted in his case by the formation of 
abscesses. 

Thus it will be seen that much difficulty is experienced by many 
in carrying out the treatment. 

Dr. Hildebrandt's reason does not seem to be the only one why 
practitioners are so troubled with this objection, since Dr. Atthill 
and others have also injected deeply. As far as I can judge, very 
few have been able, even by the most careful efforts, to achieve the 
same happy results in this respect as Dr. Hildebrandt. 

Dr. Hildebrandt, and also Dr. Atthill, select the lower part of the 
abdomen as the part in which to make the injections. 

Dr. Keating, of Philadelphia, injects just posterior to the great 
trochanter. 

Dr. Jackson selects the deltoid region, and thinks it makes but 
little difference where the insertion is made. 

Dr. White, of Buffalo, injects over the abdomen, into the cervix 
uteri, and into the substance of the tumor if it is accessible, and has 
met with no bad results. 

Dr. Wey used over two hundred injections in the abdominal region 
above the pubes in one case, and abscesses occurred in the seat of the 
puncture as often as once in eight operations. 

Dr. Dean commenced using ergot in the form of Squibb's fluid 
extract by injecting it into the cavity of the uterus through a flexible 



518 FIBROUS TUMORS OF THE UTERUS. 

catheter, but now he employs the sohition of Squibb's solid extract 
dissolved in water — one grain to five minims. Of this he injects 
from ten to fifteen drops into the substance of the cervix about 
four times a month or once a week. He thinks the effects are more 
prompt and energetic than when administered hypodermically. His 
instrument consists of a barrel the same size as the common hypoder- 
mic syringe and a tube six inches long. He has known inflamma- 
tion and suppuration to follow but once in his whole experience. 

Different Preparations. 

Believing the preparation of the medicine employed had much to 
do in causing the irritation thus observed, efforts have been made to 
find some form that would not produce the painful results thus de- 
scribed. 

Hildebrandt is now in the habit of using Dr. Wernich's formula 
for the w^atery extract of ergot, and Dr. Mund^ thinks it is very 
similar to the preparation made by Dr. Squibb. Dr. Hildebrandt 
added pure glycerin in the proportion of about one part to four of 
the solution, and the amount of the injection was forty minims. This 
contained a little over two grains of the extract, probably represent- 
ing ten to twelve grains of the crude ergot. 

Most American practitioners now use Dr. Squibb's preparation 
above referred to, some of them by dissolving it in pure water, while 
others add to the water a small amount of pure glycerin. Dr. Squibb 
recommends a solution of this extract as follows: Dissolve two hun- 
dred grains of the extract in tw^o hundred and fifty minims of water 
by stirring ; filter the solution through paper, and make up to three 
hundred minims by washing the residue on the filter with a little 
water. Each minim of this solution represents six grains of ergot 
in powder. Of this solution from ten to twenty minims are injected 
once daily, or once in two days. This is the only preparation I have 
used in hypodermic injections, and I believe it the best we can at 
present procure. 

Dr. Wey properly lays great stress on the necessity of having the 
solution fresh, believing that in a very short time it deteriorates, and 
becomes more irritating to the tissues. He says: "Ergot thus ad- 
ministered generally produces prompt effects.'' In most instances, 
in half an hour the patient experiences painful contractions of the 
uterus. The hand applied over the organ at once recognizes the in- 
creased hardness in the mass. These contractions increase in severity 
for the first two hours, and then continue with vigor for from six to 
ten hours, gradually becoming less until they cease entirely. Some 



DIFFERENT PREPARATIONS. 519 

patients suffer so much from these pains as to refuse to proceed in 
the treatment, while others bear them without much inconvenience. 
We do not always observe these painful effects even when the drug 
operates very beneficially. Sometimes the haemorrhages are controlled, 
as it were, insensibly, and the tumor slowly dscreases in size without 
the patient experiencing any considerable discomfort. It seems highly 
probable, from the statements made by my correspondents, and espe- 
cially Dr. Wey, as well as my own observations, that the benefits of 
the remedy are produced with more rapidity in the early part of the 
treatment. 

The preparation used internally more frequently than any other 
is the fluid extract, either alone or in combination with belladonna. 
Each minim of Squibb's fluid extract is equal to one grain of ergot. 
Some recommend that it be given in doses of thirty drops three or 
four times a day. Others believe that it should be given in larger 
doses less frequently repeated, as, for example, one drachm once or 
twice in twenty-four hours. It is efficacious given in either way, 
but probably more so in the larger and less frequent doses. This 
preparation is so offensive, and causes so much nausea in exceptional 
instances, that it cannot be borne. 

Dr. Squibb claims that his solid extract does not offend the 
stomach so frequently as the fluid extract. This extract may be used 
in pills coated with gelatin. A pill of five grains is equal to twenty 
grains of the crude ergot, and may be administered twice or three 
times daily. From observation of the effects of the different prepara- 
tions, I am satisfied that this is altogether the most efficient and agree- 
able for internal administration. 

A suppository for the rectum, which, in Dr. White's practice, acted 
satisfactorily, may be composed of fifteen grains of the solid extract, 
and enough gelatin to give it size and form. I have no doubt of the 
great usefulness of this method of administering ergot. 

I think it is also quite certain that the addition of belladonna in 
some cases increases the curative effects of ergot ; how much, I am 
not quite sure. Dr. Goodrich, who reached such splendid results, 
gave the fluid extract of ergot and belladonna together throughout 
the entire treatment of his case. 

From what has been said it may be inferred that hypodermic in- 
jection, if the most efficacious, is also the most objectionable method 
of using the ergot, and that in many cases the exhibition of it in this 
way is rendered entirely impracticable, because intolerable, to the 
patients. 



520 FIBROUS TUMORS OF THE UTERUS. 

May we not hope for great improvement still in the pharmacy of 
ergot? Ergot produces many good effects besides reducing the size 
of the tumors and relief of haemorrhage. I have seen, and some of 
my correspondents mention, great functional improvement in the 
more important organs. Some patients are relieved by it of obsti- 
nate constipation ; the appetite is improved, and the general health 
restored. This remarkable salutary effect is obviously due to its 
action on the ganglionic nervous system. In exceptional instances 
ergot has very disagreeable effects. Dr. Goodrich mentions inflam- 
mation of the uterus as one, and my patients often complain of great 
heat and tenderness in the uterine region. Hildebrandt speaks of 
one case in which, after the sixth injection, the patient complained of 
vertigo, imperfect control of her lower extremities, and slight spasms 
of the flexor muscles of the forearm. Dr. "Wey observed severe gen- 
eral nervous perturbation to follow its use in one instance. And Dr. 
Morris's patient discontinued treatment because of the terrible and 
tumultuous effects upon the uterus. 

Dr. E. P. Allen, of Athens, Pennsylvania, sends me the report of 
a very interesting case of fibrous tumor treated by hypodermic injec- 
tions of ergot, in which phlebitis supervened. A condition of one 
limb was produced precisely similar to phlegmasia alba dolens, and 
ran its protracted course to a favorable termination. Prior to the 
accident the tumor had very much decreased in size ; but, after the 
treatment was suspended, and during the course of the phlegmasia, 
it rapidly increased again, and the haemorrhages which had been con- 
trolled returned. After trying other methods of treatment without 
any good results, he and his patient in despair were driven to the use 
of ergot again. It was tried internally with some good effects, but as 
the remedy thus administered disagreed with the stomach, it was again 
injected hypodermically with rapid improvenient. The injections 
were used on the side. of the abdomen, opposite to that formerly 
affected with phlebitis. After a number of injections, signs of in- 
flammation of the veins were again observed, and the sound leg 
passed through all the stages of phlegmasia that had been observed 
in the first. From the intelligent observation of Dr. Wey and others, 
we may fairly conclude that it is not improper to continue the use of 
ergot during the menstrual flow. I can also add my testimony as to 
the entire harmlessness when given during that periodical flow. 

Auxiliary Treatment. 

With the exception of Drs. Goodrich and Howard, all the writers 
and correspondents quoted have depended exclusively on ergot for 



CORRECTIVE TREATMENT. 521 

the removal of fibrous tumors of the uterus ; in fact, the treatment 
has been experimental, and had for its object the solution of the ques- 
tion suggested by the publication of Hildebrandt's articles on the use 
of ergot, viz., will ergot cure fibrous tumors of the uterus? The 
course pursued was well calculated to, and I think did, test Hilde- 
brandt's treatment pretty thoroughly, but it is doubtful whether this 
exclusiveness is the best practice. The well-known alterative and 
sorbefacient medicines have, in rare instances, been credited with the 
cure of these tumors without the aid of ergot, and it is not difficult 
to understand that absorption may be promoted with more certainty 
by the alkaline bromides and iodides, where the vitality of the tumor 
is first impaired by the action of ergot on its vessels and the muscular 
fibres surrounding it. Dr. Goodrich seems to have held this view 
of the alterative treatment, as he prescribed iodide of potassium and 
bichloride of mercury with ergot. Dr. Howard also employed alter- 
atives in the same way. Both of these gentlemen combined bella- 
donna with ergot. The efficiency of this combination, as represented 
by their reports, justifies us in believing that the alteratives employed 
by them were auxiliary in a high degree. How much may be effected 
by judicious alterative and other auxiliary treatment will, doubtless, 
be determined by future observation. 

Corrective Treatment 

By this I mean treatment that will prevent or ameliorate the dis- 
agreeable effects of ergot in certain exceptional instances. The dis- 
tressing pain caused by it may sometimes be made more tolerable by 
the administration of hydrate of chloral, without very materially in- 
fluencing its other effects. Indigestion, constipation, hydrsemia, and 
nervous debility may be corrected by tonics, alteratives, laxatives, and 
stimulants given simultaneously with ergot. In short, the general 
condition of the patient should be cared for in the same rational 
manner as if ergot was not being administered. 

Modus Operandi. 

The influence of ergot over the uterus has been a familiar fact to 
the profession for a long time. It is not long, however, since we 
were aware of its effects upon the muscular fibres entering into the 
formation of other oro^ans. We now know that this medicine acts 
upon the unstriped muscular fibre wherever found, whether in the 
viscera or in the vessels of the body. 

The fibres of the uterine walls, and the arteries supplying them 



522 FIBROUS TUMORS OF THE UTERUS. 

with blood, both belong to this class ; this fact in the formation of 
the uterus renders it particularly susceptible to the action of ergot. 
The drug acts upon the uterus in a threefold manner, and causes a 
diminished flow of blood to the morbid as well as healthy tissues in 
the uterine structure. 

1st. The calibre of the arterial tubes is diminished by the contrac- 
tion of the muscular fibres which enter into their composition. 2d. 
The arterioles are diminished in size by compression from the contrac- 
tion of the uterine muscular fibres which surround them. 3d. These 
vessels are distorted and drawn in diverse directions by both the con- 
traction and compression, and hence are rendered less fit for san- 
guineous conduits. , 

Another consideration of prime importance is that, under the in- 
fluence of these medicines, the nutrition of fibrous tumors is inter- 
fered with, not only from diminution of blood in their tissues, but 
also from compression of their substance by the proper fibres of the 
uterus, their trophic energies are arrested, and are therefore made 
more susceptible to the process of disintegration and absorption. 

The great influence exerted by ergot over the circulation of the 
uterus is rendered more efficacious in the removal of fibroid tumors 
of that organ, because of the peculiar organization of the growths. 
It is now pretty well understood that this neoplasm is not very gen- 
erously supplied with arterial blood, and that its supply is derived 
from numerous minute vessels instead of one or two of larger calibre. 
From these circumstances it results that its vitality is very low, its 
circulation easily disturbed, and consequently its nutrition impaired. 

I think we are justified from observation in assuming that the 
action of ergot may be graded from an almost imperceptible to a very 
intense degree. Probably the first degree aff'ects the vascular supply ; 
the second, in addition to this, causes so much contraction as to 
merely render the fibres tense without causing pain ; and the third 
prompts the uterine fibres to vigorous and painful contraction. 

This inference is plainly deducible, I think, from the several 
modes by which tumors are made to disappear under its action, as 
well as from direct observation of the uterine fibres. 

I will now venture to call attention especially to the manner of 
expulsion of the polypoid and submucous intramural varieties. It 
will be seen from Fig. 147 that when the uterus contracts, all the 
fibres unite in pressing the polypus through the cervical canal, which 
is usually already shortened, and rendered dilatable in consequence 
of its increased vascularity. 



MODUS OPERANDI. 



523 



The cervical canal dilates, and after more or less painful efforts 
the polypus is expelled entire, covered by the mucous membrane. 
This membrane is often in a state of gangrene, but so far as I have 
observed these cases, the tumor is not broken to pieces. 

Fig. 148 represents an intramural fibroid between the central line 
of the uterine wall and the mucous membrane. It is intended to 
show a tumor where a thin layer of fibres separate it from the mucous 
membrane, and how a thick and heavy layer is spread over its external 
hemisphere. Three-quarters of the thickness of the muscular wall are 
applied to that side of the tumor. If in this position all the fibres 
of the uterus vigorously contract, the fibres near the mucous mem- 
brane must be overcome by the heavy layer outside (at c). But the 



Fig. 147. 



Fig. 148. 





opposite wall of the uterus plays an important part by supporting the 
weaker layer at the fundus of the tumor, and adding its own force in 
overcoming the capsule (at e), where it usually gives way. The posi- 
tion of the tumor makes its escape from the concentric action of all 
the fibres of the uterus impossible, and every one knows that when 
the resistance is partially overcome, the uterus is stimulated to more 
vigorous action, and the pains will not abate until the mass is ex- 
pelled. If not too large, it is driven out without undergoing great 
laceration, but if its size and attachments are such as to make this im- 
practicable, it will be broken into fragments and expelled piecemeal. 
Allow me to supplement the above description by explaining the 
effect of ergot on the sub-peritoneal and central intramural tumor. 



524 



FIBROUS TUMORS OF THE UTERUS. 



In Fig. 149, we see the disposition of the fibres on the sub-peritoneal 
variety ; next the uterine cavity there is a thick and strong stratum 
of fibres, while immediately under the peritoneum the layer is very 
thin and comparatively weak. When the uterus is acting with vigor, 
the fibres between A and B will cause those two points to approxi- 
mate each other, and the tumor will become pediculated; but that is 
all, for the tumor lays outside the field of concentric action and escapes 
the crushing influence to which the submucous variety is subjected. 

Fig. 149. 




The amount of force exerted upon it is that exercised by the weaker 
layer of fibres in a state of conquered antagonism, and the rupture of 
the capsule is impossible. 

If we take Fig. 150 as a correct representation of the fibrous tumor 
when situated in the central stratum of fibres, in which the antago- 
nism is equal at all points, it will be evident that there is no ten- 
dency to rapture of the capsule, and much less crushing influence 
exerted upon it than if it were situated slightly nearer the mucous 
membrane. 

This variety of the tumor, therefore, yields to the influence of 
ergot, only as it may be ^^ starved out " by diminution of its blood 
supply, and as the efi^ect of pressure, which we all know are the two 
conditions most favorable to absorption. 



MODUS OPERANDI. 625 

Now I think we have arrived at a point in this investigation 
where we can draw inferences as to the forms of tumors likely to be 
effected by ergot in different ways, as w^ell as those that will not be 
eflPected by it. 

AVe do not expect ergot to cause painful and efficient contractions 
in the healthy unimpregnated uterus; its fibres are not capable of 
such contraction, and it is not until the fibres have become greatly 

Fig. 150. 




developed that they are susceptible to the impressions of ergot. In 
cases of early abortion, its action is very unreliable, but after the 
fourth month of pregnancy it acts quite efficiently. 

In tumors of the uterus, the development of the fibrous structure 
is sometimes so slight that it is incapable of contraction ; there may 
be so many nuclei of degeneration that there are not enough sound 
fibres left for efficient contraction. Then, where there are many 
small tumors developed in the uterine walls, the circulation is cut ofi* 
to such a degree that they degenerate into a cartilaginoid substance, 
and sometimes they are infiltrated with calcareous material. In none 
of these cases will ergot cause any appreciable results. When, how- 
ever, there are but one, two, or three nuclei of morbid growths, as 
they increase in size the fibres undergo the development necessary to 
enable them to contract with great efficiency, and render them sus- 
ceptible to the influence of ergot. 

Another condition w^hich influences the hypertrophic growth of 
the fibres is the situation of the tumor. 

Subperitoneal tumors do not cause as great growth in the fibres 
of their neighborhood as the intramural or submucous varieties. A 



526 FIBROUS TUMORS OF THE UTERUS. 

single intramural tumor causes great development of the whole uterine 
tissues, but the development of the wall in which it is situated de- 
cidedly predominates. The submucous neoplasm so soon gains the 
uterine cavity that the development is nearly the same in the whole 
organ. 

When, therefore, we administer ergot for the cure of fibrous tumors 
of the uterus, the beneficial action of the drug will depend upon the 
degree of development of the fibres of the uterus, and the position 
of the tumor with reference to the serous or mucous surface. The 
nearer the mucous surface, the better the effects. If the tumor is 
very near the lining membrane, we may hope for its expulsion en 
masse, or by disintegration. 

We can often select the cases in which good results may be expected. 
There are four conditions which are usually reliable for this purpose. 
They are: smoothness of contour, haemorrhage, lengthened uterine 
cavity, and elasticity. A smooth, round tumor denotes, for the most 
part, uniform textural development, hsemorrhage, a certain proximity 
to the mucous membrane, a lengthened cavity, great increase in the 
length and strength of the fibres; and elasticity" assures us of the 
fact that cartilaginoid or calcareous degeneration has not begun in 
the tumor. 

An uneven, nodulated tumor may be composed of many separate 
solid masses. These displace and prevent the growth of the fibre? to 
such an extent as to render contractions inefficient. When hsemor- 
rhage is not present, the tumor is probably near the serous surface, 
and consequently not surrounded by fibres. A short ca\^ty denotes 
short, undeveloped fibres, while hardness is indicative of unimpress- 
ible induration. 

Although I have no experience in the use of ergot in such cases, 
I should expect large fibro-cystic tumors to resist its action. 

From this view of the subject, it will be seen that I freely admit 
that there is a large number of cases in which ergot cannot produce 
any good results in consequence of their nature; but there is another 
reason of equal moment why ergot may fail to act upon such cases 
as would seem to be favorable, bv the worthlessness of the dru^ and 
its preparations. 

Dr. Squibb, of New York, a high authority, says in reference to 
this subject : 

"The molecular constitution of the active portion of the drug seems, 
however, in its natural condition to be loose, aud, like a slow fermenta- 



MODUS OPERANDI. 527 

tion, to be undergoing slow molecular changes, so that by age its pecu- 
liar activity is slowly diminished uutil finally lost." 

And again : 

"The ergot in the grain, however well kept, is known to become in- 
active without any known change in appearance, though the sensible 
properties, such as odor and taste, may and probably do not change. 
Ergot, in powder, is known to diminish in activity much more rapidly 
than when in grain, and probably soon becomes inert. The tincture 
and wine of ergot are believed to change, though more slowly than the 
ergot in substance; while the extracts, and so-called ergotins, are all 
supposed to change more rapidly." 

These facts, so explicitly stated by Dr. Squibb, are very sugges- 
tive as to the causes of the frequent failures of ergot, and need no 
comment. 

When all these causes of failure are considered, the variety of ex- 
perience met with in the reports upon its trial in the treatment of 
these tumors is not surprising. It should not, however, be discour- 
aging, but should prompt us to more care in selecting the cases and 
securing reliable preparations of ergot. I have implicit faith in the 
action of ergot when all the conditions I have pointed out are present. 
I do not believe it to be uncertain in its action. 

In addition to the above conditions, I believe perseverance an in- 
dispensable condition to success, as it often requires several months 
to get the best results. 

In concluding, I desire to disclaim any expectation that ergot will 
supplant other modes of treatment. The expert surgeon will, as he 
alw'ays has, use his instruments to the neglect of remedies less sum- 
mary in their effects, and in his hands the maximum of safety will 
obtain ; but there are very few general practitioners w^ho ought, or 
would be willing, to undertake enucleation of fibroid tumors of the 
uterus. I do claim, however, that the judicious gynaecologist will 
lose fewer patients, and make more cures, by the consistent adminis- 
tration of this medicine than can be looked for from surgery. 

I am surprised that others who have written upon the subject 
should be so incredulous as to the effect of ergot, and the only way 
I can account for it is what, I think, I can see in their practice as 
related by themselves, viz., that they do not give it a fair trial. They 
fail to give it in large enough doses and persevere long enough in its 
use. The treatment of some of my successful cases extended over 
many months. When the pains that indicate efficient action, and 



528 FIBROUS TUMORS OF THE UTERUS. 

always precede disruption and expulsion occur, the practitioner gen- 
erally becomes alarmed, gives anodynes, and withdraws the medicine, 
thus abandoning the case, and declaring that ergot is a dangerous 
remedy. If he had witnessed the same, or even severer, pains in 
labor, he would have encouraged them, and so he should do in ex- 
pelling the tumor, and the result would be a safe delivery. The 
tumor would be expelled and the patient relieved. 

Before drawing my remarks on the use of ergot to a close allow 
me to mention some of the queries that have arisen in my own mind, 
or have been propounded to me by medical men. If the ergot acts 
so powerfully in expelling submucous tumors, is there not danger that 
it may rupture the capsule of the subserous variety, thus expelling 
them from the uterine substance into the peritoneal cavity, and en- 
danger the life of the patient by causing peritonitis? A proper con- 
sideration of the conditions existing in such cases will justify my 
answering this query in the negative. There is a great difference in 
the influence exerted by the uterine fibres on the two varieties of 
tumors. In the submucous variety the whole power of the uterine 
contractions is exerted toward the tumor, driving it in the direction 
of the OS uteri. When the tumor is subserous the contractions are 
from the axis of the tumor, and their effect is merely to render it 
pedunculated, and lessen the vascular supply going to it. The main 
effect, therefore, will be to check the rapidity of its growth, or to 
prevent its further enlargement altogether. This statement will suffi- 
ciently explain the effects of the medicine upon this variety of these 
morbid growths. Another question is, does the long-continued ad- 
ministration of ergot induce the gangrene of the extremities, that has 
been attributed to it? And still another, does it cause inconvenience 
or danger by affecting seriously the nervous centres? After having 
given this remedy in frequently repeated and large doses, and ob- 
served its effects with great care for a nnmber of months consecu- 
tively, I can say that I have not noticed any such consequences. I 
am not prepared to assert that there is, and always will be, immunity 
from such effects.^ The worst symptoms I have witnessed are the 
severe and persistent pains, and the apparent inflammation of the 
uterus and peritoneum, where its action has been excessive. These 
symptoms, however, have been invariably controlled by proper treat- 
ment, and have in no instance proved disastrous. In other cases, 
when the tumor was slowly disintegrated and expelled, a moderate 
form of septicaemia has invariably occurred ; but this condition has 
not been sufficiently grave to excite alarm in my mind. 



ELECTROLYSIS. 529 

A simultaneous employment of sorbefacients and the administra- 
tion of ergot would, doubtless, in some cases prove more efficacious 
than either alone. But I am free to confess that this conclusion, so 
far as I am concerned, is arrived at more from therapeutic inference 
than observation. As I am giving the results of my own observa- 
tion, more than those derived from the research of others, I deem it 
but fair to state that I have not given this combined method of 
treatment an extensive trial. 

We should remember, in the employment of any course of treat- 
ment for the cure of these fibrous tumors, that reliable results are not 
to be obtained without the long-continued use of the remedies, and a 
thoucrhtful manao;ement of them in individual cases. And I must 
say, in this connection, that I believe a want of these considerations 
has led to much false experience. The treatment of fibrous tumors, 
located in other organs than the uterus, will not serve as a useful 
guide in the management of the uterine neoplasm. The same con- 
ditions do not exist elsewhere. The tumors are nowhere else sur- 
rounded with muscular fibres whose action can be commanded by any 
remedy within our knowledge. Whether the observation of the pro- 
fession at large will or will not at present bear me out in my earnest 
belief in the curability of some of these tumors by the means I am 
now teaching," I do not know ; but I am sure that there is so much 
logic in the method that it deserves a much more extensive trial than 
has hitherto been made of it. 

Eledrolysis. 

Recently the treatment of fibrous tumors of the uterus by electro- 
lysis has received considerable attention. Foremost among those 
who are pursuing investigations in this direction stand Drs. Kimball 
and Cutter, of Massachusetts. In a report to the New York Obstet- 
rical Society Dr. Thomas gives a summary of the results of their 
treatment in thirty-six cases. The account given was very favorable, 
showing that a small number were entirely cured ; that the growth 
of the majority was arrested, while less than one-third were not 
affected by the treatment. There were but two deaths in the thirty- 
six cases, and from the report I should judge this termination was not 
the result of the operation, the conditions of both cases being hope- 
less, in consequence of the grave conditions existing in connection 
with the tumor. 

At a meeting of the American Medical Association in this city, 
Dr. Cutter was kind enough to illustrate his method of operating. 

34 



530 FIBROUS TUMORS OF THE UTERUS. 

He uses electrodes invented especially for this purpose. They 
are spear-shaped and mounted upon handles, in order that they 
may be directed with the more certainty, and made to penetrate hard, 
fibrous growths without deviating from their intended course. The 
blades are five and one-half inches long, and are insulated to within 
nearly one inch of the point. Two of these electrodes are inserted 
through the abdominal wall into the substance of the tumor, the 
points being separated by a space of several inches. Through these 
electrodes a galvanic current is passed, the electricity being generated 
by eight pairs of carbon and zinc plates, excited by saturated solu- 
tion of potassic bichromate and sulphuric acid, one part of the former 
to two of the latter. The time allowed at each sitting varies from 
three to fifteen minutes. It was said that this operation did not pro- 
duce much pain, and was usually followed by a copious flow of urine. 
The number of operations for the individual cases varied from one 
to nineteen, and the intervals between them from a day to two months. 
In certain desperate cases this seems to me to be a valuable resource. 
Although, however, in the hands of these brilliant surgeons this 
mode of performing electrolysis seems not to be attended with the 
dangers one would expect to follow such free penetration of the ab- 
dominal cavity and galvanic excitement of these growths, most of us 
would hesitate to follow their example. They will, doubtless, pursue 
this mode of treatment sufficiently to test its efficacy and danger, and 
thus enable the profession to properly estimate its value. Possibly it 
will be found, by further experiment with electricity, that very much 
smaller electrodes and a less powerful battery may produce altogether 
effects sufficient to dissipate these tumors, and at the same time greatly 
reduce the hazard of the operation. 



CHAPTER XXXV. 



SUEGICAL TBEATMENT. 



Removal of Polypoid Tumors, 

The first thing I have to say about the operations intended for 
this purpose is that they should be as simple as possible, compatible 
with thoroughness. It is not necessary to exemplify this idea. It 
is self-evident, and yet often ignored. The most effectual plan of 
avoiding danger is to have a distinct idea of the sources whence the 
danger may arise, and in connection with these tumors dangers may 
arise, (1) from laceration, contusion, or other damage to the uterus, 
resulting in hsemorrhage or inflammation ; (2) incomplete ablation, — 
the remaining portion producing septicsemia; (3) shock sometimes 
following protracted efforts at removal. This last is a very important 
source of peril. 

These dangers will, therefore, for the most part be proportionate 
to the extent of manipulation and instrumental procedure and the 
incompleteness of the operation. The old operation of tying the neck 
of the tumor, and allowing it to slough away, especially when it 
was situated in the uterine cavity, combined all the causes of danger 
above enumerated except that arising from hsemorrhage ; and it is a 
curious fact that this operation was invented for the sole purpose of 
avoiding hsemorrhage, Avhich is really the least dangerous of all, 
according to my observation. Indeed I have never seen serious 
haemorrhage caused by the removal of a polypus, however effected. 
The practice of ligating the tumor and then amputating it is to a less 
degree open to the same criticism. 

Torsion or amputation are the methods now usually employed by 
the best gynaecological surgeons of the present day, and the first is 
the one I have for several years resorted to in almost every instance. 
Amputation may be performed by the scissors, knife, by the ecraseur 
or galvano-cautery wire. All possible danger from haemorrhage will 
be avoided by the last means indicated ; but I may state that 
there is scarcely any danger of haemorrhage from the use of either of 
the other instruments. Torsion is performed by seizing the tumor 



532 SURGICAL TREATMENT. 

with strong vulsellum or fenestrated forceps and twisting the tumor 
several times around and making moderate traction until the detach- 
ment and removal are completed. In order to amputate a polypus 
when the tumor is partially or wholly expelled from the uterus the 
tumor should be drawn down with one of the forceps mentioned until 
its attachment is brought into view, when with the scissors or the 
knife the neck may be divided as close to the uterine attachment as 
possible without cutting the substance of the uterus ; or the neck of 
the tumor mav be surrounded by the ecraseur or galvano-cautery wire 
and separated by it. A tumor attached to the fundus, or high up in 
the body of the uterus, cannot always be drawn down and amputated 
in this wav without causing inversion of the organ, and consequently 
a knife in the shape of the blunt hook in our obstetric case, with an 
edge upon the concavity of the curve, will be necessary. This may 
be introduced and guided as nearly as possible to the point of attach- 
ment by the finger or hand. This process is very much facilitated 
by a piece of twine passed through a small hole in the extremity of 
the hook ; the twine should be long enough to hang out of the vagina 
and give a firm hold. When placed, the convexity of this knife 
should be turned towards the neck of the tumor and a sawing motion 
executed by the handle and twine until the tumor is cut through. 

The chain of an ecraseur may be carried to or near the point of 
attachment by means of two flexible rods with small holes in the ex- 
tremities. The wire is passed through the opening at the ends of the 
rods, and being held closely together they are introduced, carried be- 
hind the polypus, as high up as possible. One of the rods is then 
held in position while the other is carried around the tumor, thus en- 
circling it by the wire. Sometimes it will be easy to pass the wire by 
drawing a loop of it through the perforated ends of the rods, large 
enough to pass entirely around the lower end of the tumor, and as 
the rod ascends, the wire surrounding the polypus is carried up to 
the point of attachment. When well placed, the ends of the wire 
may be fitted to the ecraseur, and that instrument carried up to the 
ends of the rods. The ecraseur can then be manipulated until the 
tumor is separated. There is no need of removing the rods from the 
wire before the ecraseur is fixed, as their presence does not complicate 
the operation. 

All this explanation presupposes an open or dilatable condition of 
the OS uteri which does not always exist. If the mouth of the uterus 
is not already thus patent, it should be dilated by compressed sponges 
until it will admit of free access. 



REMOVAL OF POLYPOID TUMORS. 



533 



It requires much experience and tact to perform this operation 



with the ecraseur, and we will find in the books 
and periodicals a number of instruments intended 
to facilitate the application of the wire to the neck 
of the tumor. The dangers connected with this 
operation are those caused by the protracted ef- 
forts to replace the chain or wire of the ecraseur, 
and an inability always to remove the whole 
tumor. 

The operation of torsion can be . performed 
when the tumor wholly or partly occupies the 
vagina without any preparation, and is preferable, 
because the tumor is removed at the point of at- 
tachment. The reason of this is, the point of 
attachment is always the weakest, and yields to 
the force applied before any violence occurs to 
the other parts of the tumor or the uterine tissue. 
The tumor is thus completely removed, and with- 
out protracted manipulation. !N'o haemorrhage 
results, for two reasons: 1, there are no large 
vessels entering the tumor, and the small ones 
are torn instead of being cut as in amputation ; 
3, septicaemia does not occur, for no portion of the 
tumor is left to slough. 

When the tumor is higher up, or within the 
cavity of the uterus, torsion is equally appropriate, 
and more easily executed than amputation with or 
without ligation. Of course if the mouth of the 
uterus is not open enough to permit the seizure of 
the polypus at a point high enough to secure a 
sufficiently firm hold upon it, dilation is just as 
necessary as in the other operations. The amount 
of dilation, however, will not need to be so 
great. In performing this operation, the operator 
must guide the forceps with his fingers to the part 
of the tumor necessary to enable him to fasten 
the instrument upon or near the central part of 
the polypus. In two instances when the tumor 
was too large to be firmly held by any forceps at 
my command, I introduced the hand inside the 
uterus and detached the tumors by rotating them 



Fig, 151. 



Chasignac's Ecraseur. 



534 



SURGICAL TREATMENT, 



with the hand until they were detached, and afterwards making trac- 
tion with the forceps. I brought them into the vagina and delivered 
them with the obstetrical forceps. One of these weighed forty-six 
ounces. 

To perform torsion for the removal of a polypus, the surgeon, 
after fixing the instrument firmly in the desired position should be 
careful to twist it enough to be sure of its detachment before com- 



FiG. 152. 




EMSARGEfiJT Chicago. 

Small Vulsellum. 

mencing traction. Not less than from four to six complete revolu- 
tions should be effected. This procedure will prevent the danger of 
lacerating the tissues of the uterus. 

The greatest objection urged against the operation of torsion is the 
likelihood of lacerating the wall of the uterus at the point of attach- 

FlG. 153. 




£-.//. SA/?GE/^r Chicago. 

Medium-sized Vulsellum. Forceps. 

ment. If we will call to mind what was said about the relative 
thickness of the muscular strata upon each side of the different kinds 
of fibrous tumors, we will at once perceive the groundlessness of this 
objection. In the pendulous variety, the whole wall of the uterus is 

Fig. 151. 




Large Vtilsellum Forceps. 



outside the point of attachment and is strong enough to resist the 
very few fibres that are carried down with it. Indeed in the polypus 
there is almost no substantial attachment except that formed by the 



REMOVAL OF POLYPOID TUMORS. 535 

investing mucous membrane. If, therefore, the torsion is performed 
with sufficient tliorous^hness before traction is begun, laceration of 
more than the superficial tissues surrounding the neck of the tumor 
is next to impossible, and consequently the operation is perfectly safe. 

Haemorrhage is not so likely to occur after torsion as when the 
tumor is amputated by the knife, or scissors, or even by the ecraseur. 
The danger of haemorrhage, then, is an objection that cannot with 
any show of reason be urged against torsion. I have never seen 
haemorrhage succeed torsion. The contractions of the uterus which 
take place after removing the polypous growth from the cavity of the 
uterus in the great majority of cases is as effective in the prevention 
of haemorrhage as it is when its contents are expelled at the time of 
labor. I trust that it is not necessary to dilate further upon this part 
of the subject. However, let me remind the reader that as haemor- 
rhage, although improbable, is yet possible, we should be prepared 
for it. After what has been said under palliative treatment about 
the management of this complication, it will not be necessary to en- 
large upon that point. 

After an operation of this kind the only treatment necessary is 
perfect quietude for a few days, cleanliness by injections, and if need- 
ful the administration of anodynes to quiet pain. AYhen a tumor 
has been removed from high up in the uterus the patient should of 
course be carefully watched, and if symptoms of inflammation or 
septicaemia arise they should be treated by suitable measures. 

Surgical operations having the relief of haemorrhage for their 
primary object, but which sometimes eventuate in the cure of the 
tumor, have been recommended and successfully practiced. 

The first I shall mention, is that brought into general notice by 
the late J. Baker Brown, viz., incising the cervix. 

Mr. Brown first discovered that free incision of the cervix would 
check haemorrhage by doing it as a preliminary step to coring or goug- 
ing out some of the tumor. He says, in tumors of recent origin and 
moderate size, free incision not only checks the haemorrhage, but often 
arrests the growth of the tumor, and even causes its disappearance. 

Of fourteen cases thus treated, in two only was it necessary to 
incise or gouge the tumor. 

When the vagina is small he first dilates it with bougies (some 
prefer sponge surrounded by thin india-rubber tubing). After the 
preparation of the vagina is satisfactorily accomplished, he exposes 
the cervix by introducing Sims's speculum, seizes, fixes, and incises it 
freely, its whole length from within outward with Simpson's metro- 



536 SURGICAL TREATMEN'T. 

tome, the incisions being made on both sides. He then plugs the 
cavity thus made with lint saturated with sweet-oil (if the oil was car- 
bolizecl it would be better . to prevent hemorrhage and to exclude 
air- Mr. Brown lays great stress upon a thorough plugging of the 
cervix after the operation, and filling the vagina w-ith cotton to sup- 
port the cervic-al plug. He allows this to remain for forty-eight 
hours. He insists upon making the incision in the cervix to extend 
within the internal os uteri. The cavity produceil in the cervix by 
the incision should be kept dilated until the surfaces cicatrize. If 
then the symptoms are not relieved, he proceeds to the operation of 
gouging out a piece of the most dependent part of the tumor. This 
may be done with a knife, but he prefers pointed scissors. 

The object of removing a part of the tumor is to inaugurate a de- 
structive inflammation, which will result in the disintegration and 
expulsion of the tumor. 

Sir J. Y. Simpson introduced the cauter}^ or caustics into the sub- 
.stance of the tumor for the same purpose. In two instances I have 
caused fibrous tumors to disappear bypassing cotton-wool into them. 
A large trochar was thrust through the cervical cavity as deep into 
the tumor as practicable, and after the stilet was withdrawm, several 
pieces of cotton secured by thread around them, were passed to the 
extremity of the canula into the tumor and held there by a probe. 
while the canula was also withdrawn. A discharge of fetid pus and 
serum followed moderate inflammation, and the tumor grew smaller 
until it d:-:yy-::;.r-d. 

^\ ith Lnyprc.--nt experience. I would commend the administration 
of ergot, as soon as the tumor was effected by either of these opera- 
tions, with a view to aid in the expulsion of the growth. 

For the relief of excessive haemorrhage. Dr. Atlee passed a blunt- 
pointed bistoury into the cavity ot the uterus, and by turning the edge 
of the instrument upon the tumor, cut deeply into it. The dilata- 
tion of the cervix, so generally indispensable, can be done by com- 
pressed sponge or sea-tangle tents, instead of incision. 

iLny.c^to.tion. 

This term is applied to the operation of splitting the capsule and 
turning the tumor out of its bed. 

In favorable cases this operation is easily performed, but such 
cases are very rare ; generally it is one of the most formidable and 
dangerous operations that we are called upon to perform. I say this, 
with reference to the operation, when it is done bv the most skilful 



ENUCLEATION. 537 

and efficient gynaecologist. In the hands of the reckless, unin- 
structed, and inexperienced, it is still more likely to be done badly* 
and indeed barbarously than any other operation. 

The operation of enucleation should be confined to submucous 
tumors, or to speak more definitely, to tumors situated between the 
central stratum of muscular fibre and the mucous membrane. The 
intrusion of such tumors into the cavity of the uterus enables us to 
attack them from that cavity, and the thick, strong layer of muscular 
fibre lying outside of the tumor, makes the operation less dangerous 
by protecting the peritoneal cavity from the violence which might 
otherwise result from the most cautious use of the instruments. 

When are we justified in making an attempt at enucleation ? 

The first item in the answer to this question is, when it is evident 
that the patient's life will soon be sacrificed if the tumor is not in 
some way disposed of. The second item is, where every reasonable 
palliative measure has been tried without success, or where there is 
not time to wait for their trial, if such a condition can exist ; and I 
may add a third, where appropriate attempts have been made and 
failed to break them up and expel them with ergot. Some will 
object, saying that ergot will not do this w^ith any uniformity ; to 
which I would answer, that I do not believe the objectors have 
given it a thorough and intelligent trial. Some will further object, 
by saying, that the septic fever attendant upon such expulsion is 
more dangerous than the operation of enucleation ; to w^hich I would 
answer, that my cases will not bear out the objection. I will 
also add, that the general practitioner will conduct a case of ex- 
pulsion more successfully than he can the operation of enuclea- 
tion. 

The first step in enucleation is thorough dilatation of the cervix, 
if it is not already sufficiently open. The dilatation should be suffi- 
cient to permit the fingers to pass as far up into the cavity of the 
uterus by the side of the tumor as they can be made to reach. If 
the vagina is small, it should also be prepared by stretching or dilat- 
ing it. 

When these conditions have been obtained, the patient should be 
placed upon her left side with her left hand behind her, and by 
Sims's speculum, the cervix and tumor exposed to view. The cervix 
should then be seized with vulsellum forceps, drawn down as much 
as possible, and held firmly by an assistant until the operation is 
completed, varying the direction of the traction as the operator may 
require. The capsule may then be opened by making an incision 



538 



SURGICAL TREATMENT. 



with loDg curved scissors, at the junction of the tumor with the wall 
of the uterus the whole width of the tumor ; at the middle of the in- 
cision another should be commenced, and carried as high up over the 
longitudinal centre of the tumor as possible. 

These incisions should not penetrate the tumor to any great depth. 
They should simply divide the capsule, and when the capsule is not 
adherent, the space between it and the tumor will be easily recog- 
nized. 

The fingers can then be inserted between the capsule and the 
tumor, thus separating them as high as the operator can reach. 
This separation should extend around the whole circumference of 
the growth. 

The fingers will not be long enough, usually, to reach over the 
upper end of the tumor ; the separation may be completed by Sims's 
enucleator as seen in Fig. loo. It may be passed with the concave 



Fig. 155. 




Siins"s Enucleator. 

side next to the tumor, gently to the top, and then passed around in 
any direction until the separation is complete. 

While this last part of the operation is being accomplished, another 
vulsellum should be fastened upon the tumor as high up as possible, 
and by traction made to depress and steady it. When the tumor is 
thus separated from its capsule, we should make an effort to turn it 
upon its longitudinal axis. 

Fig. 156. 




Sims"s Guarded Hooks to aid in drawing the Tumor. ■ 

This will enable us to determine whether it is entirely detached 
or not, as well as to dislodge it from the muscular bed into which 
it has been moulded. If the detachment is not complete, the point 
of resistance Avill generally be discoverable by swaying it from one side 
to the other, or backward and forward, thus enabling us to apply the 
enucleator to the right place, and complete the separation. At this 
stage of the operation we may make more traction, the dislodgement 



ENUCLEATION. 539 

will be facilitated by pressure upon the fundus of the uterus by the 
hand of an assistant. When the tumor is not too large, it will de- 
scend as we pull upon it, and pass out through the vagina. If, how- 
ever, it is so large that it cannot be made to pass through the vagina 
in this way, then the tumor should be split by the scissors from the 
bottom upward, as near the top as possible, without danger of wounding 
the fundus of the uterus, and then (as Dr. Sims instructs us) one-half 
should be seized by the vulsellum and drawn down, so as to cause 
the tumor to undergo evolution ; the portion grasped coming down 
first, and by virtue of its attachment at the top, brings the other after 
it ; but if this cannot be done, we must cut off the part in the grasp 
of the vulsellum, seize another portion and treat it in the same man- 
ner, until the whole is removed by pieces. 

Under favorable circumstances this operation may be performed 
as above described ; but obstacles will sometimes be met with that 
will give the best operators much trouble, and render the results 
very unsatisfactory. 

The first I will mention is that presented by imperfect capsulation, 
or adhesion of the tumor to the walls of the uterus. Some cases occur 
where the tumor is not isolated by a capsule from the uterine struc- 
tures, but the substance seems to be continuous with them. 

Whether this condition depends upon original formation, or is the 
result of disease, which causes adhesion between the surfaces of the 
tumor and the capsule, I am not able to say; but in either case it 
presents an insurmountable obstacle to the perfect removal of the 
tumor ; and, if this condition could be diagnosed beforehand, it would 
contraindicate the operation for enucleation. 

When in the performance of the operation we meet with this ob- 
stacle, and can clearly ascertain its existence, I think it would be best 
to gouge out as much of the tumor as we could safely remove, and 
then commence the administration of ergot, to remove the remainder. 
I would do this, because cutting through the superficial layer of the 
tumor would be sure to disturb its vitality. 

The next obstacle to the removal of the tumor by enucleation is 
the great size to which it may attain. I have already spoken of the 
necessity of sometimes cutting the tumor in pieces with scissors to 
facilitate its removal. The wire ecraseur will often be very useful 
in lessening the size of the tumor. 

We slip the wire over a portion of the tumor and cut it off, then 
pull down more wdth the vulsellum, when that is possible, and pass 



540 SURGICAL TREATMENT. 

the wire over another piece, and so on until it is small enough to 
remove. 

This plan, where practicable, and especially in the hands of the 
experienced operator, is the safest way. Dr. Thomas's serrated spoon, 
or a very small, crescent-shaped knife, such as is used by Dr. E. 
Warren Sawver, of this city, for cutting into and removing mass, 
may, by careful use, aid us in this respect. 

Haemorrhage constitutes a very formidable complication, in rare 
instances, in the operation of enucleation. I have never met with 

Fig. 157. 




Thomas's Serrated Spoon. 

this difficulty in the removal of these tumors by any method ; but 
there are too many cases on record to leave any doubt that we should 
be provided with the means of meeting haemorrhage of the most 
formidable degree. 

In considering this matter in relation to the cases reported, I 
believe it to be the result of inertia, or want of firm contraction 
in the muscular fibre, or on account of the separation of a vessel in 
the uterine walls. In. either case, if we continue the operation, we 
should follow the example of Dr. Emmet in throwing ice- water freely 
into the cavity of the uterus. I would also resort to obstetric doses 
of ergot ; both of them would serve to contract the vessels of the 
uterus, and overcome the inertia by prompting the uterine fibres to 
act. If, in spite of these remedies, the haemorrhage is so copious as 
to make delay veiy dangerous, we may inject the uterus with tinc- 
ture of iodine ; but I should greatly prefer immediate and complete 
plugging to anything else. If the haemorrhage has been sudden, shall 
we proceed with the operation? I think not, but would assign this 
to the category of cases which should be treatsd by ergot. 

What has been said of enucleation has reference more particularly 
to deeply-seated submucous tumors which project into the cavity, but 
are imbedded their whole length in the wall of the uterus. The more 
superficial or sessile variety of submucous tumors project so far into 
the cavity as to appear to be implanted upon the wall beneath the 
mucous membrane of the uterus. The attachment, or base, upon 
which it sits, is nearly or quite the size of the tumor. This variety 
can be removed with much more facilitv. 



LAPAROTOMY. 



541 



After exposing the tumor, and steadying it by traction with the 
vulsellum, it may be separated from the wall, and that very neatly 
by the serrated spoon. This instrument should be inserted through 
the capsule, at the juncture between the tumor and the uterus, by a 
rotary sawing motion ; the growth severed by passing it through the 
capsule in any direction where the attachment exists. 

This is Dr. Thomas's method of removing this variety of tumors. 

Dr. Emmet pulls them steadily and persistently down into or toward 
the vagina ; this allows the upper portion of the uterus, from which 
the tumor is withdrawn, to contract. Further traction upon the 
tumor gives room for the fibres beneath the point of implication 
also to contract, until the circumference of the attachment, becoming 
smaller, assumes a pedunculated form, and may be severed by the 
ecraseur, scissors, or knife. This form of tumor may also be removed 
by passing an Ecraseur over and amputating a part of it, and then, by 
means of the finger or enucleator, remove the remainder. 

Patients who have undergone any of these operations for removal 
of fibrous tumors may die from shock, haemorrhage, inflammation, 
or septicaemia. 

For the treatment of shock, I will refer the reader to the subject 
as taught in the after-treatment of ovariotomy. 

I have already said sufficient upon the subject of treatment of 
haemorrhage as a complication in such cases. 

Inflammation, when it occurs, should be treated as in the after- 
treatment of ovariotomy. 

Septicaemia may be more effectually treated in connection with this 
than almost any other of the great operations, as we can keep the 
cavity clean by hot- water injections, and disinfected by carbolic acid. 
For the general treatment, I will refer the reader to the after-treat- 
ment of ovariotomy. 

Laparotomy, 

For the extirpation of the tumor, is another surgical resource, of 
which we may avail ourselves under circumstances where the em- 
ployment of less hazardous measures are either impracticable or un- 
availing. 

The extirpation of the tumor, where it is subserous and pedicu- 
lated, has been performed a number of times successfully; and where 
the tumor is not adherent, there is no great difficulty in removing it 
in this way. 

The incision through the abdominal wall may be made in the same 



5J2 SURGICAL TREATMENT. 

place and in the same way as for ovariotomy, although it will be 
uecessar}^ evidently to make it larger. 

The pedicle being exposed and ligated by a double silk ligature, 
it will be found that the substance through and around which the 
ligature is passed, is not so firm as the pedicle of an ovarian tumor; 
hence it will be necessary to be more careful, lest it give way and 
cause secondary hsemorrbage. 

The ligature should not be passed through any part of the tumor, 
but between it and the uterine substance; then, to get sufficient sub- 
stance beyond the ligature, the capsule may be divided an inch from 
the ligature and the tumor enucleated. 

When the tumor is sessile, instead of being pediculated, and the 
base too broad to be included in a ligature or clamp after the abdo- 
men has been opened, it may be enucleated by splitting the capsule 
and peeling it out with the fingers. I would suggest that when 
enucleation has been thus performed, that an opening be made from 
the bed of the tumor into the uterus, so that the discharge from the 
empty capsule may find its way out through the uterus and vagina. 

To secure this evacuation, we might pass a drainage-tube through 
the opening into the vagina. Where this, or some other effective 
arrangement for drainage is made, the capsule may be closed by 
silver sutures, and the abdominal wound treated as for ovariotomy. 
If the capsule should not be large, and the operation has been per- 
formed, as it always should be performed, under the antiseptic con- 
ditions, it may not be necessary to make any provisions for drainage. 

When a subserous tumor is situated on the posterior wall, occupy- 
ing the cul-de-sac behind the uterus, it may be removed by making 
an incision along the median line of the posterior vaginal wall and 
removing the tumor through the vagina. Dr. R. S. Sutton, of 
Pittsburg, has successfully removed one in this way, as also has Dr. 
Clifton Wing, of Boston. 

Of course none but the small-sized tumors can be removed in this 
way. 

The thermo-cautery, or the actual cautery, should always be in 
readiness to stop haemorrhage in either of these operations. 

Laparo-hyderotomy. 

The last measure I will mention, as one resorted to for the relief 
of patients afflicted with these tumors, is laparo-hysterotomy, or the 
removal partially, or wholly, of the uterus with the tumor. 

This operation resembles in many respects that of ovariotomy. 



LAPARO-HYSTEROTOMY. 543 

Our preparation of the patient should be the same. The anaesthetic 
and the carbolic spray are used in the same way, as also is the anti- 
septic dressing. 

When we undertake the operation, we should be especially well 
prepared with means of arresting haemorrhage. To this end we 
should have in readiness the thermo-cautery, a number of haemostatic 
forceps, persulphate of iron, etc., and every other arrangement should 
be complete, so that there might be no delay from this cause, as the 
operation is almost of necessity one of long duration under the most 
favorable circumstances ; and it should be remembered that every- 
thing, except haste, which may shorten the duration of the operation 
is of great importance, as the longer the operation lasts, the more 
depressing its effects. For fear that what I may say should encourage 
precipitation, I would protest against hurry, and advise deliberation 
in all the steps of the operation. 

The incision is made in the same place and manner as in ovari- 
otomy ; first a small incision, say four inches long, for exploration, to 
ascertain the character of the tumor, its probable adhesions, and its 
relation to the viscera. As some viscera, especially the intestine, is 
more frequently found to lie across the front part of the tumor, the 
necessity of ascertaining any such condition is much greater than in 
ovariotomy. 

When it comes to the separation of the adhesions and the removal 
of the tumor, the size of the incision must be increased sufficiently to 
permit the extraction of the whole mass, instead of an effort being 
made to lessen the size of the tumor, as in ovariotomy. 

An exception may be made to this teaching, if the tumor is not 
entirely solid, but of the fibro-cystic variety. In this case, if a large 
cyst presents itself, we may hold the tumor close to the incision with 
vulsellum forceps and evacuate the fluid through a large trochar, or an 
incision into the wall of the cyst. If in doing this we find there are 
a number of cysts, we may introduce a finger, or even the whole hand, 
as I once did, into the centre of the tumor, and break it up as far as 
possible. In this way we may sometimes very greatly lessen the size 
of the tumor. 

In this operation, as in ovariotomy, the size of the incision is of 
great importance ; in no case should we risk bruising or tearing the 
abdominal walls. 

In operating for fibrous tumors, we should not trust to the sound 
in searching for adhesions ; the hand alone should be used, and the 



544 SURGICAL TREATMENT. 

whole surface examined before any attempt is made to dislodge the 
tumor. 

We should also remember that the adhesions, as a rule, are more 
vascular than in ovarian tumor, and hence, when necessary, they 
should be ligated twice and cut between the ligatures. 

When solid, the tumor may be lifted from its bed more easily by 
means of the vulsellum forceps than by the hands. After it is lifted 
out, the uterus will generally be found to be removed from the pelvis 
with the tumor constituting a part of the mass. 

If there are no more adhesions, the junction between the body and 
the cervix uteri should be sought for and ligated at this point with a 
strong double ligature. 

Before applying the ligature to the pedicle, remember that the 
bladder is in danger in consecjuence of its proximity. We should 
remember also, that the tissues in the pedicle are less yielding than the 
pedicle of the ovarian tumor. 

" Dr. Leon Labbe communicated, at a late meeting of the Academic 
de Medicine, a note relative to a modification of the operation of hys- 
terectomy as applied to fibrous tumors (exsauguinification of the tumor). 

" Gastrotomy applied to the treatment of fibrous tumors of the uterus 
is an operation about which there is no longer any dispute. The note 
which M. Labbe communicated to the Academy is not for the purpose 
of describing this operation, but simply to make known an important 
modification that he has introduced in the operative process. 

"The quantity of blood contained in these enormous uterine tumors 
is always considerable ; it is certain that the loss of this blood by the 
ablation of the tumor is a factor, the importance of which cannot be 
passed over, especially if we consider that the extirpation of these tumors 
almost always takes place in the cases of women who are in an advanced 
state of cachexia. Based upon the principle which had led Esmarch to 
apply a compress bandage on limbs which were to be amputated, M. 
Labbe thought the same bandage could be utilized to press back into 
the general circulation the blood contained in large uterine tumors, and 
thus practise a kind of transfusion. 

'"The patient for whom he had occasion to apply this principle for the 
first time, was in a deplorable condition before the operation, and she 
succumbed six days later to septicemic symptoms; but M. Labbe has 
been able to prove that the enormous fibroma upon which compression 
was first practiced was entirely exsanguined, and that about a litre of 
blood was by this means restored to his patient. 

" The theory which led M. Labbe to apply Esmarch's compress to re- 
store to the general circulation, at the time of their extirpation, the 



LAPARO-HYSTEROTOMY. 545 

blood contained in such great abundance in the fibro-myomas of the 
uterus, is very clearly justified by the case which has been reported to 
the academy. 

" The peculiar conformation of the tumor was such that no very par- 
ticular method was employed in this case ; but if the tumor to be operated 
on is more regular in form we would have just reason to fear that 
the application of the elastic band might present some difficulties. In 
this case, to fasten the band and give it a support we should transfix the 
tumor near its summit by one or more metallic needles. Several of 
these needles may even be placed at diflferent heights so as to give sup- 
port to the compress, and to prevent its slipping. 

"M. Labbe concludes : 

"1st. That there must be a positive advantage in operations on large 
uterine fibro-myomas removed by gastrotomy, in restoring to the patient 
the blood which these tumors always contain in large quantity. 

" 2d. That this result may be employed in a complete manner by 
applying to the tumor Esmarch's compress, or any other compress en- 
dowed with the same elastic properties." — Gazette Hehdomadaire, 6 Aouty 
1880; American Journal Medical Sciences, October, 1880. 

When the ligature is satisfactorily applied we must remember also 
that in cutting away the tumor there is great danger of retraction of 
the parts included in it. The abdomen must be carefully cleansed 
and haemorrhage entirely checked before closing the wound. 

The after-treatment of these cases is more difficult than in ovari- 
otomy, as the shock is ordinarily much greater, and inflammation and 
septicaemia more likely to follow the operation. 

I have performed the operation three times, and in all instances 
lost my patients from the severity of the shock. My cases were of 
the fibro-cystic variety. 

I do not believe the complete extirpation of the uterus and ova- 
ries will bear any reasonable comparison with ovariotomy, even 
double ovariotomy. 

In comparing these operations we must remember that when the 
uterus and both ovaries are removed, the whole genital system, with 
all its reflex capacities and sympathetic relations, is suddenly torn 
from its connections. The complex system of nerves supplying these 
organs with centric connections, the moral, emotional, and physical 
energies they are continually exerting over the whole of the rest of 
the organism are destroyed. The importance of the relations between 
the genital system of woman and the rest of her body and brain is so 

35 



646 SURGICAL TREATMENT. 

great that it can scarcely be appreciated. These relations constitute 
the major part of her life. 

From such considerations, I can but believe that the shock of this 
operation is incomparably greater than in ovariotomy or double 
oophorectomy. 

When one ovary is removed, the other maintains the ovarian in- 
fluence over the uterus and the system at large. When both are 
removed, there is still left the larger part of the genital nervous 
system, with its relations, although impaired, not entirely severed; 
and we know, from observation, that in such cases womanhood is 
well preserved. 

In operations of this kind, conservative surgery is of the greatest 
importance, and we ought never to remove the ovaries when we can 
preserve them. 

While there will continually occur cases for which this operation 
is the only remedy, experience will prove it to be an operation of 
much more gravity than ovariotomy in any of its forms. 

Kimball, Burnham, H. R. Storer, Thomas, and other Americans 
have performed this operation successfully. 

In Europe, Pean, Koeberle, Wells, Clay, and others have con- 
tributed toward perfecting hysterectomy for fibrous tumors. 

Oophorectomy — Battey^s Operation — Spaying. 

These are terms intended to designate an operation for the removal 
of the ovaries. 

To Dr. Robert Battey, of Rome, Georgia, is due the credit of first 
removing the ovaries for the purpose of artificially inducing the 
menopause. 

The knowledge that the change of life generally brings relief from 
the intolerable and irremediable forms of obphoro-neuroses that so 
often perplex the practitioner, would lead to the hope that the re- 
moval of these bodies would produce similar cures. This operation 
has been before the professional public for about seven years, and there 
are reported, according to Dr. Paul F. Munde [American Journal of 
Obstetrics), up to this time 120 cases, with an average mortality of 
22.6 per cent. Dr. Mund6 very correctly observes that if the posi- 
tive benefits of the operation were as assured as the favorable rate of 
mortality, the opposition to it would soon cease. The operation has 
also been repeatedly performed for the purpose of arresting the growth 
of fibrous tumors of the uterus, on account of the favorable effect the 



LAPARO-HYSTEROTOMY. 647 

natural menopause so generally produces upon them, and in some 
instances with very favorable results. 

We should not forget, however, that menopause is not the change 
of life. 

This condition — menopause — is sometimes brought about by some 
of the very conditions for w^iich Battey's operation is performed 
without producing change of life. 

It is true that the ovary, if not the essential agent, is certainly 
necessary to the proper development of the female genital organs. 
After the genital apparatus is mature, it is probably the fountain of 
the excito-motor influence upon which depends the functions of the 
uterus and its appendages in all their relations to the generative acts. 
The ovaries ought not, therefore, to be classed as appendages to the 
uterus ; rather the latter is, in the proper sense, an appendage to the 
former. 

As an accompaniment of ovulation, which is the development and 
disengagement of the ovule, the trophic energies of the uterus are 
excited in corresponding degree. 

The repletion and activity of its circulatory system corresponds to 
like changes transpiring in the ovaries, and the nervous system of the 
uterus is acted upon by that of the ovaries, prompting glandular 
changes in the mucous membrane. 

Even the intramenstrual growth and hypertrophy of fibrous and 
other tissues of the uterus are but the reflex complement of the 
stromal hypertrophy of the ovaries. As the ovarian excito-motor 
stimulation is withdrawn from the uterus, involution simultaneously 
occurs in the two. It is true that the removal of the ovaries with- 
draws the source of the excito-motor influence from the uterus, and 
this generally brings about the menopause in the sense of the cessa- 
tion of periodical haemorrhages; but the same operation, after the 
uterus has obtained maturity of organization, and especially when its 
tissues have become hypertrophied (vascular, nervous, and muscular), 
leaves a large, highly organized organ without its regulating appa- 
ratus, the subject of any morbific cause which in its nature has any 
aptitude for the production of uterine derangement. 

We see this illustrated in the case given by Dr. Trenholme, the 
after-history of which, subsequent to the operation, I give below. 

This, I think, is the effect produced by suddenly removing the 
ovaries in large fibrous tumors of the uterus. In smaller growths, 
and a less vascular state of the uterus, the same conditions exist, and 
the same consequences will follow, only in a less noticeable degree. 



548 SURGICAL TREATMENT. 

The senile menopause, one of the symptoms of the change of life, 
is the consequence of gradual changes in all of the organs concerned. 
This change is a degeneration of the genital organs. 

The tissues are not merely diminished in size^ but they degenerate 
into those of a lower order of organization, and this same degenera- 
tion extends itself to the morbid growths of the organs. 

Tumors lose their vascularity, their fibres disappear, and the whole 
becomes a degenerate mass. 

It is not certain how much of this general and regular degenera- 
tion is due to the presence of the ovaries and their exci to-motor ener- 
gies in prompting it and in governing its nature. 

It is a plausible supposition, however, that as the ovarian changes 
and influences are so great in building up the uterus and sustaining 
its functions, that it might be as efficient in its retrograde transfor- 
mation, thus making it more complete. 

The removal of the ovaries in the presence of a large fibroid and 
hypertrophied uterus, simply takes away their governing agency 
before the process of degeneration has begun. We have then a 
highly organized uterus and tumor, and if degeneration takes place 
at all, — which I very much doubt, — it is not normal in any respect, 
and may be the cause of morbid instead of salutary conditions. 

"We then exchange one evil for another ; a greater for a lesser it 
may be ; to the advantage of the patient somewhat, but yet not so as 
to make a perfect cure. 

Dr. E. H. Tenholme, of Montreal, reports a case'^ of abdominal 
oophorectomy for a large fibrous growth of the uterus in January, 
1876. Severe uterine pains and haemorrhage were the actuating 
reasons for the operation. The patient according to her own account 
was very much improved for four months succeeding the operation, 
the uterus then (in May, 1876) suddenly commenced enlarging and 
gave her very great pain. The enlargement and pain were accom- 
panied by copious hsemorrhage. As the result of this attack, she 
was confined to her bed more or less constantly for three months. 
Recovering from this attack she Avas able to support herself a part of 
the time as a saleswoman, and a part of the time as a nurse, for 
several months. 

In December, 1877, she had a similar attack and of like duration. 
The patient has now been in this city about two years, and I have 
had the opportunity of seeing her in two or three of these attacks. 

* Obstetric Journal of Great Britain, October, 1876, p. 430. 



1 



LAPARO-HYSTEROTOMY. 549 

The pain is exceedingly severe and requires the use of anodynes in 
considerable doses to relieve it. In April, 1878, one of these attacks 
commenced and kept her in bed for several weeks. And in Decem- 
ber, 1879, another similar attack prostrated her, with pain and haemor- 
rhage, lasting until the middle of March, 1880. 

During the whole continuance of this attack she was in the 
Woman's Hospital, of the State of Illinois, under my immediate 
supervision. During the early part of this last paroxysm, the uterus 
was enlarged until it extended two inches or more above the umbilicus, 
and occupied all of the central and lower portion of the abdomen to 
within two inches of the crest of the iliac bones on either side. 

Since the subsidence of the symptoms, the size of the uterus and 
tumor have decreased about twenty-five per cent. 

It is now somewhat elastic, whereas, during the early part of the 
paroxysm it was very firm. 

The health of the patient is so very poor and uncertain, and she so 
dreads the suffering she experiences during the attack, that she now 
begs the removal of the entire mass. She is an intelligent woman 
and has made herself quite conversant with her condition, and the 
extreme measures sometimes resorted to for relief, and is entirely 
willing to abide the consequences of the operation. 

I am deterred from indulging her wish for removal of the tumor 
by hysterectomy, from the apparent general and very firm adhesions of 
the front surface of the tumor to the anterior walls of the abdomen. 

Whether this patient's life has been prolonged by the operation or 
not, of course no one can know. That her condition, so far as suf- 
fering is concerned, has been greatly improved, I think no one wit- 
nessing her agony and prostration during a paroxysm would hardly 
believe. And while I have no doubt of the thoroughness and skill 
of the operation, I must say I believe it to be a partial failure. 

In presenting these reflections on the difference between the effect 
of a natural change of life and oophorectomy upon fibrous tumors of 
the uterus, I do not wish to be understood as opposing oophorectomy 
altogether. They, however, make me hesitate to give an uncon- 
ditional adhesion to the practice, even where in our present knowl- 
edge it would seem indicated. 



550 



SURGICAL TREATMENT. 



The following table, showing the result of all the reported cases 
within his reach, was published by Dr. Mann, October, 1880:* 









Primary 
Result. 


Secondary- 
Result. 


Reference. 


' Operator. 


S 
1 


ft 


t 

o 


'6 

1 


Trenholme, 
Hegar, . . . 

Goodell,. . 

Martin, . . 

Kaltenbach, 
Freund, . . 

Shroder, . . 

Tait, . . . 

Pernice, . . 
Von Nussbaum 

Tr«' ■ • 

Mann, . . 


^> • 


1 
13 

2 

2 

1 
3 

1 

11 

1 
1 
1 
1 


1 
10 

1 

2 

1 
9 

I 

1 


*3 

1 

1 
1 

2 

*1 


1 

7 

1 
2 

2 

9 

1 
1 
1 


1 

1 


Obst. Journ., G. B. & S., 76. 
Centralbl. f. Gynaecology, No. 

21-79. 
Goodell, Lessons in Gynaecology, 

2d ed. 
Centralbl. f. Gynaecology, No. 

21-79. 
Hegar, Journ. Klin. Vortrage. 
Centralbl. f. Gynaecology, No. 

21-79. 
Centralbl. f. Gynaecology, No. 

21-79. 
British Med. Journ., July 10, 

1880. 
Arch. f. Gyn., Bd. xiv, H. 3. 
Goodell, loc. cit. 
Personal Communication. 




38 


29 


9 


25 


2 





















Dr. Mann thinks that the operation when performed for fibroids, 
should be through the abdominal wall ; as they are generally re- 
moved from their normal position, by being lifted up as the uterus 
becomes larger. 

The effect of removing the ovaries for intolerable and incurable 
cases of oophoro-neuroses, is quite another thing ; for then we re- 
move the cause of the disease, or rather the symptoms ; because, as 
they are the organic origin of the neuroses, their condition is the 
disease, and like amputating a limb, that is incurably diseased, to get 
rid of the symptoms, we cut off the ovaries for the same purpose. 

There is another side to this subject, however, and that is the 
general condition of the patients, who are the subjects of these nervous 
symptoms, is such, as, in part, to account for their suffering. And 
we sometimes find that a radical change in the circumstances under 
which they live, will dispel their trouble. Instances of this kind must 

* Oophorectomy for Uterine Fibroids, by Matthew Mann, A.M., M.D. Clinical 
Lecturer in the Medical Department of Yale College. American Journal Obstetrics, 
October, 1880. 



LAPARO-HYSTEROTOMY. 651 

have fallen under the observation of most practitioners of long ex- 
perience. Muscular labor, outdoor exercise, and the loss of luxuries, 
when brought by inexorable bad fortune, have done wonders in the 
way of removing oophoro-neuroses. 

Then the question comes up, whether we ought to spay our patient 
or prescribe and enforce the proper amount and kind of primitive 
living necessary to revolutionize her nervous functions. 

The former course is the easiest, and, I am sorry to say, most 
acceptable to some patients. 

The following are Dr. Battey's* conclusions as to the proper cases 
for o5phorectomy : 

" It is not a question as to whether extirpation of the ovaries shall be 
resorted to, or whether valerian or asafoetida be given, or resort be had 
to any other known resource of gynaecology, but the case must be nar- 
rowed down to this, as the only expedient available." 

The following are the classes in which he regarded the operation 
as justifiable: 

" 1. Congenital absence of the uterus, coupled with ovulation, in which, 
at the menstrual epochs, there are violent vascular and nervous per- 
turbations, that are either dangerous to life or destructive to the health 
and happiness of the patient. 2d. Complete occlusion of the utero- 
vaginal canal. 3d. Certaincasesofmenstruo-mania, absolutely incurable 
by any of the known resources of medical science or art. 4th. Ovarian 
epilepsy. 5th. Certain cases of chronic ovaritis. 6th. Certain cases of 
amenorrhoea. 7th. Ovarian hernia. 8th. Submucous or interstitial 
fibroids. 9th. Incurable flexion of the uterus. 10th. Csesarean sec- 
tion." 

This last, of course, means cases in which patients cannot be de- 
livered per vias naturalis. 

In deciding whether or not he should advise the operation, he asks 
himself three questions : 

" 1st. Is this a grave case ? 2d. Is it a case incurable by any other 
known resource of medical and surgical art? 3d. Is it curable by the 
menopause ?" 

If all are satisfactorily answered in the affirmative, he regarded the 
case as a proper one by the operation known as Battey's. If either 

* "What is the Field for Battey's Operation?" A paper read before the Amer- 
ican Gynaecological Society in Cincinnati, September 1st, 1880, by Dr. Kobert Bat- 
tey, of Eome, Georgia. 



552 SURGICAL TREATMENT. 

question cannot be answered satisfactorily, he regarded the case as 
one in which the operation is not justifiable.* 

While these positions are not all as definitely put as they ought to 
be in a matter of so great importance, one thing is made plain by 
them, and that is, Dr. Battey regards the operation as a last resort. 

We are not yet able to do more than practice Battey 's operation 
according to the imperfect light we have upon the subject, because it 
is the only available means of relief we can command. By intel- 
ligently watching effects we will be able after awhile to arrive at 
definiteness of indications for its employment. 

Physical and Psychical Results. 

I have four patients from whom I have removed both ovaries, 
whom I occasionally meet, and, so far as I can see of them, and from 
explicit assurances given by them, I believe they are not unsexed in 
any other sense than that they are sterile, and do not menstruate. In 
morals, manners, appearances, affections, propensities, and voice, they 
remain the same. 

The operation of removing the ovaries per vaginam was first per- 
formed by Dr. Battey. After exploring the posterior and vaginal 
walls Dr. Battey made an incision in the central line, about one inch 
and a half long, and with his finger drew the ovaries through the 
opening, ligated them and cut them off. 

Since then the operation has been repeated in the same way by 
others. The ovaries have also been removed a number of times 
through the abdominal walls. The main obstacle to be met in the 
performance of the operation is the adhesions arising from previous 
or existing inflammation. Sometimes this obstacle is so great that 
the operation through the vaginal wall is extremely difficult, and 
occasionally quite impossible. In such cases laparo-oophorectomy 
would be the easiest operation. 

The incision in this operation should be made in the same place as 
for ovariotomy, and no larger than is necessary. Hegar sometimes 
removes the ovaries through an opening an inch long, but probably 
two inches will be a more frequent incision. 

* October No., 1880, American Journal of Obstetrics. 



CHAPTER XXXVI. 

THE OYAEIES. 

The ovaries are situated upon each side of the uterus, to which 
they are attached by a strong fibrous ligament about one and a 
half inches in length, and they occupy the posterior part of the broad 
ligament just behind and a little below the Fallopian tubes. 

AVhen in their normal position they are slightly below the linea 
ilio-pectinea, and somewhat anterior to the sacro-iliac synchondrosis. 

When their size and weight are somewhat increased by congestion 
they may vary from their normal locality by sinking lower down in 
the pelvis. The peritoneal membrane is reflected around them, and 
embraces the lower two-thirds of their substance, while the upper 
border stands out free in the peritoneal cavity and in contact with 
some of the fimbria of the Fallopian tube. 

The entire organ is inclosed in its proper fibrous covering, the 
tunica albuginia, which is extremely dense and firm in structure and 
incloses a peculiar firm, spongy substance, or stroma, held together by 
delicate connective tissue, and abundantly supplied with bloodvessels. 

In the meshes of this spongy stroma are numerous dark micro- 
scopic points, which by some are supposed to be the points around 
which the ovisacs are formed. 

In each ovary of the adult woman may be seen several ovisacs of 
diflPerent dimensions, from the size of a pin's head to that of a pea. 
The main body of the stroma presents a delicate buff color when in- 
cised. 

Method of Examining the Ovaries. 

The ovaries are situated so deep in the pelvis as to make them seem 
to be inaccessible to every means of investigation. In very fleshy 
persons it is indeed difficult to reach them, but even in most of such 
patients we can gain valuable information by thorough and perse- 
vering effort, and in women of thin habit we can generally reach 
them with the finger. When it is remembered that there are very 
few of the diseases to which these organs are subject that do not in- 
crease their volume and weight, and that in displacements of the 
uterus they are frequently drawn down below their natural place, 



554 THE OVARIES. 

we shall not be at a loss to understand the possibility of generally 
procuring information by the right kind of an examination. 

The most simple plan of examining them is to introduce the index 
and middle fingers as deeply into the vagina as possible, and direct 
them high up in the pelvis to the side and behind the uterus, while with 
the other hand above the pubis we press the pelvic contents down as 
low as we can. To do this in the most effective manner the patient 
should lie on her back across the bed, or on the operating-table, so 
that we may have the free use of both hands. If we do not reach 
the ovary in this way it is very proper in some cases to etherize the 
patient, and introduce the hand all but the thumb. We may thus ex- 
plore the sides of the pelvis quite thoroughly, and, in favorable sub- 
jects, will seldom fail to find and get a pretty good idea of the state of 
the organ. The ovary is rather nearer to the anus than to the vaginal 
orifice, hence an exploration, with one, two, or more fingers in the 
rectum, may lead to definite results, with less inconvenience to the 
operator. It should be said, however, with reference to examinations 
per rectum, that they are both more painful and disgusting than 
those through the vagina, and should be resorted to only when we 
cannot succeed in getting the proper information by examination 
through the latter canal. In rectal explorations we may avail our- 
selves of the bimanual method, and the pressure above will be of 
more service than when examining per vaginam. 



CHAPTER XXXVII. 

AFFECTIONS OF THE OVARIES. 

Congenital Atrophy. 

The ovaries, like the rest of the genital organs of woman, may be 
imperfectly developed. It is not unusual to meet with women whose 
whole sexual system is developed to a degree usually found to indi- 
cate the completion of childhood. The breasts are about the size and 
shape of the girl twelve years of age. She does not menstruate, and 
perhaps is not endowed with the sexual desires common to the sex; 
and if married, fails to bear children. The uterus, if examined, is 
found small, as are the clitoris labia and nympha. In all the instances 
of this kind that have come under my observation, the individuals 
were otherwise well developed. Not unfrequently, however, as shown 
by other observers, the whole person is deficient, never attaining to 
more than the stature of a child. Cases of the congenital atropliy of 
the ovaries are given in this work under the head of amenorrhoea, 
with the method of treating the condition. Senile atrophy of the 
ovaries needs no description in this place. 

Hypertrophy. 

Enlargement of the ovaries is probably occasionally due to an in- 
crease in size without other alteration of their tissues. This is hyper- 
trophy. It is supposed to result from prolonged congestion, causing 
hypernutrition of the organ. The disease is hypothetical, as it has 
not been demonstrated. 

More frequently the enlargement is caused by an increase of some 
of the natural tissues and by inflammatory effusions. This last en- 
largement is, of course, due to chronic inflammations. It is not easy, 
if at all practicable, to diagnosticate hypertrophy of the ovaries. We 
can generally detect enlargement of these bodies by physical exami- 
nation, but cannot in all cases determine with certainty the nature of 
the enlargement. 

Displacement. 

Their intimate and firm ligamentous connection with the fundus 
of the uterus causes them to partake of the changes in the position of 



556 AFFECTIONS OF THE OVARIES. 

that part of the organ. Thus, when the fundus rises into the ab- 
dominal cavity during pregnancy, the ovaries are carried up with it, 
and in very thin persons they may sometimes be felt as small, mov- 
able, sensitive tumors upon the side of the uterus. 

The same thing occurs in some cases when the uterus is much 
enlarged by a fibroid tumor. In the former condition the displace- 
ment is physiological, and does not ordinarily give rise to serious 
inconvenience, unless the organ is rendered unusually sensitive by 
disease. When the uterus is retroverted or retroflected, the ovaries 
are displaced to a greater or less extent downward and backward, and 
sometimes this displacement is so great that they may be felt in the 
posterior cul-de-sac and constitute a very annoying complication. In 
fact, this condition is of more consequence than the uterine displace- 
ment, and is a serious barrier to the correction of the malposition of 
the uterus, on account of their, liability to be compressed by the in- 
strument used to hold the uterus in place. But sometimes the ova- 
ries fall into this position without the uterine deviation. When this 
is the case there are likely to be many grave symptoms, which are 
included in the vague and imperfectly understood term "ovarian 
irritation.^' In most cases of this nature the ovaries are the sub- 
ject of some form of organic disease, and we may reasonably doubt 
whether the symptoms arise from the pre-existing disease any more 
than from the deviation from their normal position. There can 
be no doubt, however, that the displacement may greatly embarrass 
the circulation in them, and thus contribute still farther to their mor- 
bid condition. In such cases, the extensive reflex nervous influence 
exerted through the genito-spinal centres awakens a long chain of mor- 
bid phenomena destructive of the comfort of the patient, and some- 
times establishes a series of oophoro-neuroses that wrecks the patient 
mentally and physically. 

Finally, I may say that rarely these organs may make their way 
out through the inguinal canal, in something of the same way that 
the testes do in the male. As there is no scrotum, however, in which 
they can find lodgment, they are arrested at the upper border of 
the pubis, and there constitute a harassing and painful hernia. This 
ovarian hernia may generally be diagnosed from the omental or in- 
testinal hernia, from the facts, first, that these two latter seldom pass 
out through the inguinal ring in the female, though frequently through 
the femoral ring ; second, that they are not particularly sensitive to 
the touch unless in a state of inflammation from strangulation, while 
the ovary is quite sensitive; and, third, that the sensitiveness of the 



DISPLACEMENT. 557 

ovary is said to be peculiar, resembling nothing so much as the sick- 
ening sensation experienced upon pressing the testicle, while the 
sensation of omental or intestinal hernia is rather the tenderness of 
inflammation. 

Having referred to the different varieties of ovarian displacements, 
I desire now to confine myself to the pelvic deviations of position. 

Symptoms, 

What are the symptoms of pelvic displacements of the ovaries ? 
Having already referred to them, I shall be brief in their further 
consideration. 

They may be included under two heads, local and general. The 
local symptoms are not distinctive. They are pain, weight, or bear- 
ing-down sensation, sometimes heat in the pelvis, backache, sacral 
and coccygeal tenderness, and occasionally radiating neuralgia ; 
there are also very frequently though not always, menstrual derange- 
ments, but these local symptoms may be produced by many of the 
disorders incident to most of the pelvic organs. 

As to the general symptoms. They are quite numerous and varied. 
It is indeed questionable whether all of the hystero-neuroses should 
not be regarded as oophoro-neuroses ; that is, direct or indirect morbid 
emanations from the ovaries themselves. It is probably impossible 
for us to separate the general symptoms arising from disease of the 
pelvic viscera into uterine, ovarian, vaginal, and vulval, as the nerve- 
supply to these organs are essentially a unit, and for their nervous 
manifestations are subject to the same presiding centre. 

In them is comprised a circle of functions to the perfection of 
which, soundness in all of the organs is essential. Whether the ter- 
rible nervous symptoms arising from certain diseases of the vulva, 
the vagina, or the uterus can be reflected upon the organization in any 
otter way than through their connection with the ovaries is a ques- 
tion not yet solved. I think we cannot doubt, however, that to " ovarian 
irritation^' may be attributed the whole array of reflex phenomena so 
frequently noticed in the wrecked condition of broken-down women. 

In the retrouterine displacements of the ovaries, these conditions 
are prominent features, the numerous symptoms often assuming a 
very aggravated form, and the suffering of the patient becoming un- 
endurable. The general symptoms are those of ovarian irritation, 
and this is to be expected, because the circulation and the innervation 
of these organs must necessarily be very much interfered with by 
their malposition. 



558 AFIECTIOyS OF THE OVARIES. 

Th.e Din gnosis 

Of these displacements is not generally very difficult. AVheu in the 
inguinal canal, an examination of the tumor, its shape and peculiar 
sensitiveness are both characteristic, the only thing for which it may 
be mistaken is hernia of the omentum or intestine, and a tumor 
formed by the protrusion of either of these is more globular, less 
firm, and unless in a state of inflammation is not very sensitive. 
When in the cvl-de-sa.c behind the uterus if not changed in shape by 
disease the ovary has the same outline as when naturally situated 
and is movable. TTe may reach it by passing one or two fingers 
deep into the vagina or rectum. 

In many instances this displacement is associated with retrover- 
sion or retroflexion of the uterus, and is apparently the result of the 
malposition of that organ. In others, however, the ovaries fall behind 
the uterus, because of their enlargement and increased weight from 
structural disease. Possibly a relaxed condition of the fold in the 
broad ligament in which it is contained, may peruiit the ovary to 
settle down out of its natural position. 

Are displacements of the ovaries always and necessarily accom- 
panied by serious local symptoms or destructive general disturbances ? 
I think not. Probably every gynaecologist of extensive observa- 
tion has noticed instances, in which the ovaries could be felt in the 
cul-de-sac, and the patient experience little if any inconvenience, 
from such malposition. These, judging from my own observation, 
are not very uncommon cases. 

Why should some patients suffer so much from these displace- 
ments while others experience so little inconvenience from them ? 

In answering this, I must employ a term that is not very definite, 
and perhaps not always intelligible, " nervous susceptibility." This 
nervous susceptibility with some patients, appeai-s to be a part of 
their original construction or " make up '' if you please, while with 
others it is an acquired condition. 

Xervous susceptibility and neurasthenia, if not connected as cause 
and effect are at least very intimately associated, and to treat these 
cases successfully therefore, we must have in mind tliis item of 
nervous susceptibility or neurastlieuia connection. 

Prognosis. 

When displacements give rise to symptoms of ovarian irritation, 
what is the prospect of relief? 



TREATMENT. 559 

Such cases are justly regarded as very unpromising, but not neces- 
sarily incurable. 

Treatment. 

The treatment of the symptoms attendant, and to some extent de- 
pendent upon displacements of the ovaries, is sometimes followed by 
most satisfactory results. By treating the symptoms, I do not mean 
the administration of medicines for the relief of nervous headache, 
hysterical convulsions, sleeplessness, etc., but the removal of those 
conditions from the system which encourage their manifestation. 

Whatever may have been the diathesis of our immediate ancestors, 
whether they were effected by diseases resulting from hypersemia or 
plethora or not, it is evident that we have fallen upon times when 
ansemia or hydrsemia among women, is, to say the least, a very com- 
mon state of the general system. This is especially the case with a 
large proportion of patients suffering from ovarian irritation, either 
with or without displacements of the ovaries, and the nerve centres 
in such people are habitually ansemic. 

Nervous exhaustion means imperfect nutrition or lack of trophic 
energy in the nerve centres. This, I have no doubt, is mainly be- 
cause there is not a sufficient amount of good, rich blood circulating 
through them. 

I cannot understand how nervous exhaustion can take place when 
there is an unfailing supply of nutrition in these centres, but it is plain 
that an exhaustion of supply will render the regular working of the 
brain and spinal cord impossible. It is blood exhaustion then in- 
stead of nerve exhaustion. 

What we want to do with these patients is to turn them entirely 
around in their habits, and lead them to the adoption of measures 
that will make them plenty of blood and fat. Dr. Weir Mitchell 
has taught us how to do this, and his system of managing patients 
of this character is admirable. It is not always practical nor in- 
deed necessary to adopt his method as a whole. This, however, 
does not detract from its merits. Absolute rest is necessary only in 
cases of extreme prostration. 

In most cases active exercise will be better than passive, and 
should always be enjoined upon the patient and attendants. The 
exercise in kind and quantity should be prescribed and enforced with 
exacting regularity, and urged by decision that will not fail. 

The most important part of the treatment, however, is the regula- 
tion of food, by which I mean the prescription of it in items and 
quantity from day to day. 



560 AFFECTIONS OF THE OVARIES. 

My routine prescription is three ounces of beefsteak for break- 
fast, with bread and butter, or toast, potatoes, and other vegetables, 
as the capacity for digestion will allow ; six ounces of roast beef or 
mutton, bread and butter, potatoes, vegetables, etc., for dinner ; for 
supper the same as for breakfast, and after each meal, and at bedtime, 
one pint of good fresh milk. The only limit I would place upon 
the amount of food of the kind I have indicated is the capacity of 
the stomach to retain it. If the food is not rejected by vomiting, or 
it does not irritate the bowels enough to cause diarrhoea, I would not 
allow the want of appetite nor the inconvenience that may arise du- 
ring digestion to be considered as a reason for not taking it. 
Usually the stomach will soon become tolerant and, after a time, the 
enriched blood, circulating through its glandular apparatus, will en- 
gender a relish for food, and the patient will eat with pleasure. This 
intimation, that an ansemic stomach necessarily digests with difficulty, 
is intentional, for I do not believe that energetic innervation is possible 
without the supply of blood is sufficient to secure good digestion. 

With this, or some other equivalent method of feeding the patient, 
there should be associated some plan by which she can get plenty of 
fresh air, and have as much exercise as she is able to take. The ex- 
ercise may be passive at first, but as soon as it is possible it ought to 
be active. 

Active exercise may be begun by having the patient walk, sup- 
ported as much as necessary by a strong nurse, but as soon as she can 
walk alone the support should be withheld. Then it is not rest, 
but exercise, that should be advised in these cases. Of this I am 
fully convinced by experiments and unmistakable proofs in my own 
practice. 

As long as nutrition can be supplied the patient will profit by ex- 
ercise, but if nutrition is impossible then of course exercise is impos- 
sible also. Thus far I have said nothing about medicines to aid 
digestion or to increase nerve force, not because I have no faith in 
them, but because I believe them of secondary importance, mere ad- 
juvants instead of principals in the treatment of this condition of the 
system. 

I could cite a number of instances in which this course of manage- 
ment resulted in averting the dangers and mutilation of the more heroic 
treatment of castration by establishing a vigorous and tolerant con- 
dition of the nerve system, and thus curing ovarian irritation. These 
suggestions are applicable in other cases than displacements of the 
ovaries in which there is ovarian irritation. 



OVARITIS. 561 

As to the management of the displacement. In some few cases, 
when the ovaries are borne down by a displaced uterus, we may 
occasionally correct the displacement so far as to greatly improve the 
circulation of these organs, and thus remove a great element in ova- 
rian distress. This, of course, is done by correcting the displacement 
of the uterus, by proper means of support, as a well-adjusted pes- 
sary. 

In the cases, however, in which the symptoms are the most grave, 
— retroversion and retroflexion of the uterus, — the location of the 
ovaries in the cul-de-sac by the side of the fundus renders the satis- 
factory adjustment of the pessary almost impossible, as the instru- 
ment is pretty certain to cause pressure upon these sensitive organs, 
and thus become intolerant. We ought not to despair of accom- 
plishing the object, however, until we have exhausted our ingenuity 
in mechanical appliances for this purpose. 

When every other measure fails either to render the condition of 
the patient bearable, or save her from becoming a mental and physi- 
cal wTeck, we still have the resource furnished us by Dr. Battey, of 
Rome, Georgia, namely, the removal of these organs. In taking the 
consequences of this operation, however, we should remember that it 
is very dangerous, and that, if successful, it unsexes our patient in 
the sense that she is at least barren for all future time. AVhen the 
ovaries are displaced so as to occupy the inguinal canal the operation 
for removing them is less hazardous than when in the pelvic cavity, 
and for that reason may be resorted to with less hesitation. 

Ovaritis. 
Acute inflammation of the ovaries, in connection with local peri- 
tonitis, or inflammation of the cellular tissue in the pelvis, is not an 
uncommon affection. As a simple, uncomplicated disease, it is con- 
ceded to be of infrequent occurrence. Post-mortem examinations 
reveal the existence of inflammation of the ovaries, as a com])lication 
of inflammation of the surrounding tissue, in all stages, from mere 
phlogistic hypersemia to destructive suppuration. In such instances 
it is involved in the general mass of disease. This occurs after abor- 
tion, labor at full term, and even in the more puerperal condition, as 
the result of cold. As ovaritis in this connection is the disease 
causing no separate symptoms, and requiring no other treatment than 
is necessary for the cure of the inflammation accompanying it, all 
that is requisite to say upon the subject will be found under the head 

of perimetritis. 

36 . 



562 AFFECTIONS OF THE OVARIES. 

As the result of the infrequent occurrence of ovaritis in an un- 
complicated state, our knowledge of it is very meagre, many experi- 
enced practitioners never having recognized it. The intense interest 
the profession now feel and manifest in diseases of women will soon 
lead to a clearer understanding of this subject. 

The following case is the nearest approximation to simple acute 
inflammation of the ovaries ever observed by the author: 

"January 5th, 1872, I was called to see Mrs. S., widow, aged thirty- 
five years. She is the mother of three children, the youngest of whom 
is eight years old. She had been attacked fourteen days before with pain 
in the hypogastric and iliac regions; chill, nausea, headache, and great 
nervous excitement. Fever succeeded the chill, and the nausea was 
sometimes accompanied by vomiting. The pain continued, and was 
aggravated by the erect or sitting posture. She was attended by a 
homoeopathic practitioner, and after a few days improved until she was 
able to sit up a part of the time ; but the pain, accompanied with ten- 
derness upon pressure in the iliac region, continued in a subdued degree. 
Upon the 13th, about 10 p.m., after having exerted herself too much, 
she had another chill, with an aggravation of the symptoms. In the 
morning, when I was called, I found her vomiting, and unable to retain 
anything but cold water. She had headache, with pain and tenderness 
in both iliac regions. There was no tumefaction. The pulse was 110 
to the minute ; the tongue was coated white ; the mouth dry, and other 
febrile symptoms usual in moderate attacks of acute inflammation were 
present. The attack had occurred at the time the menstrual flow was 
subsiding, and was attributed to exposure after being overheated and 
fatigued. At the time I saw her there was no discharge from the 
vagina ; the passage of the urine gave her pain of a burning character, 
and she suffered pain also in passing the faeces. Upon examining per 
vaginam with the finger I could feel both ovaries prolapsed and tender. 
The uterus was prolapsed somewhat; also swollen and tender to the 
touch. Upon making pressure in the hypogastric region the patient 
complained of but little tenderness. Downward pressure in the iliac 
region caused more pain, and increased the sensations of tenderness in 
the pelvis. The ovaries, as felt through the vagina, were tender, mov- 
able, and appeared to be three times their natural volume. The pa- 
tient complained of increased nausea when they were touched in 
the examination. I found no difficulty, by using the fore and middle 
fingers, in examining them thoroughly and recognizing their shape and 
size. The diagnosis was moderate inflammation of the uterus, with more 
acute inflammation of the ovaries. The patient informed me that she 
was not aware of being the subject of chronic inflammation of the 



TREATMENT. 663 

uterus, as she had not previously suffered from pelvic pain or incon- 
venience, indicating chronic disease of any kind about the uterus or 
ovaries. There did not seem to be local peritonitis nor cellulitis, and 
but slight metritis. The bladder was irritable, and the vagina slightly 
tender. 

" Treatment. 
"Four grains of calomel were given, and succeeded in eight hours by 
a saline cathartic. Poultices were applied to the hypogastric region, and 
the patient ordered to keep quiet in the recumbent posture. The cath- 
artics operated well, and relieved much of the pain and suffering. One- 
fourth of a grain of morphia enabled her to rest with some degree of 
comfort. When the pain returned the morphia was repeated, and thus 
continued when necessary for the pain. The bowels were kept soluble 
by the administration of a fluidounce of the saturated solution of citrate 
of magnesia. By continuing this course of treatment for six or seven 
days the inflammation was subdued, and convalescence was fairly estab- 
lished, In three or four weeks she was entirely well, and still remains so." 



CHAPTER XXXVIII. 

AFFECTIONS OF THE OVAKIES CONTINUED— OVAEIAN TUMORS. 

Anatomy. 

In the proper ovarian tumors, we may trace three coats or layers 
of tissue forming their walls. The external is the serous or perito- 
neal. It is shining and smooth as this membrane is elsewhere, and 
seldom changed in any way, except it may be thickened and hyper- 
trophied. It can be traced into the peritoneal covering of the viscera 
and abdominal parietes, and consequently needs no elaborate descrip- 
tion. The internal coat or lining membrane is doubtless the mem- 
brana granulosa of the ovisac, very much hypertrophied. When 
small, something like epithelium seems to be its entire composition. 
As it grows and develops, the epithelial arrangement is less perfect, 
until, when very large, we can observe it only in patches. In many 
cases when thus large, this membrane has a smooth, lustrous appear- 
ance, but in others it is more or less thickly studded with granular 
projections, varying from almost imperceptible minuteness to the size 
of peas, or even larger. Regarding the main sac as an hypertrophied 
ovisac, I think these little granular sacs (for they prove to be sacs 
upon examination) are also of the same nature and are the origin of 
the numerous endogenous or supplementary growths which constitute 
one of the polycystic varieties. 

The middle coat is made up from the stroma of the ovary. Its 
strength depends upon quite a considerable amount of fibres, which 
enter into its composition. As the tumor develops, these fibres are 
enlarged, and apparently, if not really, increased in numbers, until 
they constitute the most of the thickness of the walls, and in some 
parts make quite a thickness, density, and toughness of tissue. These 
qualities are greater in old large sacs than in the smaller and younger 
ones. At the pedicle, and for some distance up the sides, they are 
greater than in other portions, being in these parts sometimes a quar- 
ter of an inch thick, while at the fundus or distal portion they may 
be thin and fragile. The whole of this coat may be very tough and 
thick, so as to resist great force, or it may be thin throughout, so as 
to be easily ruptured at almost any point. Entangled in the meshes 
of these fibres may be discovered, in many cases, the minute micro- 



NATURE AND ANATOMY. 565 

scopic points so numerously scattered through the substance of the 
ovaria. These points are believed to be the origin of the germinal 
spot in the ovum by some physiologists, and around which are de- 
veloped the ovum, and progressively the whole ovisacs and their 
contents; and I believe that their presence in the walls of the tumors, 
over much, if not the whole, of their extent, accounts for the devel- 
opment of the minute granular internal projections above described. 
In a tumor recently removed from the body, by holding it up to the 
light, we may not unfrequently discover the peculiar buffy tinge seen 
in the stroma. The vessels are situated in this coat. They are nu- 
merous and some of them large, so large that great care is necessary 
to prevent them from bleeding when the peduncle is divided. They 
are developed, it is hardly necessary to say, to this great size from 
the minute twigs w^hich penetrate the substance of the ovary. 

The shape of ovarian tumors may vary much. They may be regu- 
larly globular, polyglobular, angular, or irregular in almost every 
way. AYhen small, the ovary may be seen as constituting a consider- 
able portion of the tumor. When large, the ovary may be almost 
lost in the walls, or observed as a mere tubercle sticking to or im- 
bedded in its side. Generally but one ovary is the seat of disease, 
but in rare instances both are aifected. Ovarian tumors divide them- 
selves anatomically into monocystic and polycystic, — the one having 
a single cystic cavity, the other several. The polycystic variety is 
formed by the development of several cysts adjoining or by the side 
of each other, and independently attached to or springing from each 
other on the external surface, or within the cavity of one large one. 
The instances of polycysts growing by the side of each other, and 
being independently attached, resembles at first the single. At an 
early stage of development they may stand free of contact one with the 
other, but as they grow in size, in consequence of the small surface 
of the ovary to which they are attached, they crowd together, so that 
it is not always easy to say whether they were not developed from 
each other. The cysts from which smaller ones grow are called pro- 
liferous. They are doubtless single for some time in their early de- 
velopment, but carrying up, as they increase in size, the proper sub- 
stance of the ovary, with its rudimentary ovisacs, after awhile the 
inner or outer surface is bulged by the maturity of these last, which, 
if they do not dehisce and allow the escape of the ovum, grow into a 
subordinate tumor. This process is separate until there is a glomera- 
tiou of cysts to quite a number, from four to fifty, of various sizes, 
from the size of a man's head down to that of a pin's head. Small 



666 OVARIAN TUMORS. 

ones may be so numerous as to stud a large part of the inner surface 
with granulated elevations. This is the most frequent variety met 
with in practice. When the minor sacs grow from the inner surface 
of a large cyst, the tumor is denominated olygocystic. 

There is a great difference in the sensible qualities of the contents 
of the cysts in different cases, and of the different cysts in the same 
case. In some it is very thin, in others very thick and tenacious, 
while the color shades from black, inky, to limpid clearness. Not 
unfrequently large fibroid growths are observed in the ovary at the 
base of a single or multiple cystic tumor. These solid fibroid or 
fibrous growths may be simple or benign in their nature, or malig- 
nant. This complication of ovarian dropsy I think more frequent 
in persons advanced in years — over forty — than younger ones. The 
contained fluid of the polycystic tumor is ordinarily highly albumi- 
nous, of high specific gravity, tenacious, and more or less colored. 
The fluid is so thick sometimes as not to flow through a canula. 
Occasionally we meet with sacs which contain blood; more frequently 
serum colored with blood; in others pus, or serum and pus. From 
one tumor of several cysts, I drew pus from one cyst; dark coffee- 
grounds sanguineo-serous fluid from another; a beautiful straw color 
from another; and lastly, from another, fluid of a delicate azure tint. 
After tapping, more or less alteration is observed in the fluid, each 
operation withdrawing fluid affected by chemical or pathological cir- 
cumstances. In the former, putridity or acridity; in the latter, the 
purulent productions of inflammation. 

There are some chemical and microscopic resemblances in the fluid 
from almost all varieties of ovarian tumor. Albumen in some of its 
forms is always present. In some specimens of fluid, strong acids, 
or heat, causes it to assume a solid form, coagulating and adhering 
like the white of an egg when cooked in boiling water ; in others a 
small precipitate is all that is observed. Between these extremes all 
shades of difference exist. The reaction is alkaline. Mr. Nunn 
says that, '' As the results of many examinations (microscopic) of 
different specimens of ovarian fluid, the most constant characteristic 
of such fluid is its containing, in greater or less abundance, cells 
gorged with granules; and, in addition, circumambient granules, 
having the same measurement, encompassed by the cell. The size of 
the gorged cells and included granules varies greatly, even in fluid from 
different cysts in the same ovary.'^ This description of fluid could, 
with certainty, remain good of the first evacuation only, as pus and 
blood-globules are not unfrequently found in subsequent evacuations. 



NATURE AND ANATOMY. 567 

The fibrous or solid variety of ovarian tumors is occasionally met 
with. Dr. Bogue, about ten years since, removed a solid tumor of 
the ovary at the Cook County Hospital, which weighed forty ounces. 
It was very dense and fibrous in structure. 

The very remarkable tumor called dermoid is so seldom met with 
and so little is said of them in the textbooks that I feel justified in 
copying somewhat at length from my article on dermoid ovarian 
tumors, in the third volume of the Transactions of the American 
Gynaecological Society : 

Case I. — In the spring of 1874, the patient, a girl, eighteen years 
of age, noticed an enlargement in the left iliac region, which finally 
became so great that in October, 1875, she was distressed from the 
distension. At this time she was tapped and about ten quarts of 
fluid evacuated. The physical nature of the fluid was somewhat 
tenacious, of a clear, slightly bluish tinge, and contained the ovarian 
cell. The outline of the tumor could be traced quite easily after the 
tapping. It occupied the whole width of the abdomen between the 
two iliac fossse and extended upwards to within two inches of the 
umbilicus. It was globular and of soft consistence. 

After this operation the tumor filled quite rapidly, and on Jan- 
uary 1st, 1876, the patient was as large as before the fluid was 
evacuated. 

On January 4th, ovariotomy was performed. There were no ad- 
hesions or other source of embarrassment to the removal of the tumor, 
and the patient made a good recovery. 

The sac was thin but firm, and presented the peculiarly pearly 
aspect of the ordinary ovarian tumor. When the large Wells's trocar 
was introduced nothing but serum flowed through the tube. Upon 
being opened the tumor was found to contain about half a pound of 
sebaceous fat. The inner surface was smooth, except a small part 
about the size of the palm of the hand situated at the bottom near 
the pedicle. Here the surface was depressed at least an inch below 
the level of the inner surface, and, although not sacculated, had a 
well-defined and pursy margin. The bottom of this depression was 
covered with dermic tissue, and upon it grew an abundant crop of 
dark -brown hair about an inch long. It was very fine, and firmly 
attached. Doubtless the dermic patch was the source of the fatty 
material found floating in the cyst which on cooling assumed the 
consistence and appearance of yellow butter. Upon closer inspection 
of the smooth lining of the larger part of the tumor it was found to 



568 OVARIAN TUMORS. 

be studded with very miaiite papillae, such as we sometimes see in 
oligocystic ovarian tumors. 

This specimen I regard as not a true dermoid cyst, but as a com- 
plex dermo-ovariau tumor, a tumor originating in a Graafian follicle 
in which a tegumentary element had been inclosed. It contained no 
bone or teeth such as are often found in the true dermoid tumor, but 
did contain undoubted colloid fluid, diluted with the watery pro- 
duct from the sweat glands of the dermic membrane upon which the 
hair was implanted. 

Case II. — Mrs. P., aged forty-three years, the mother of one 
child eighteen years old, became aware of an enlargement of the 
abdomen about ten months before the operation, which was performed 
June 28th, 1876. During that time she grew to the size of preg- 
nancy at full term. The tumor filled the abdominal cavity and ex- 
tended to the eiisiform cartilage. There was no difficulty in deciding 
that it was monocystic and contained a thin fluid. The operation 
was not attended with difficulty in any respect. There were no ad- 
hesions, and after evacuation the sac passed through an incision only 
three inches long. The patient experienced considerable depression 
from the shock of the operation. This, however, lasted but a few 
hours, no other disagreeable symptoms supervening. The recovery 
was rapid. The care of the case after the operation was undertaken 
by Dr. S. W. Green, of Marengo, Illinois. 

The cyst was single, thin, and uniform, except at the part opposite 
the pedicle, where its wall was about half an inch thick and contained 
a thick layer of adipose tissue. Upon the inner surface of this part 
was a thick tegumentary covering, upon which was implanted a dense 
mass of blonde hair, matted together, and nearly the size of an 
orange. The whole of the inner surface of the sac elsewhere was 
smooth and of a bufF color. The external surface was of a pearly 
hue and smooth. There was no evidence of bony or dental tissue. 
The fluid was quite thin, of a slightly blue tinge, and floating in it 
in considerable masses were ten to twelve ounces of yellow sebaceous 
fat. The hairs when straightened out measured from six to fifteen 
inches in length. 

This example I regard as a simple dermoid cyst of the ovary, there 
being no sign of follicular papillfe upon the inner surface, and the 
fluid not being in the least tenacious or colloid in appearance ; more- 
over I was unable to find in it the ovarian cell. I think the fluid 
was the product of the sweat glands in the dermic structure at the 
bottom of the cvst. 



NATURE AND ANATOMY. 569 

Case III. — Mrs. P., a small Jewess, thirty-one years of age, the 
mother of four children, the youngest being three years old, noticed 
about nine months before the operation — which was performed April 
7th, 1875 — that the abdomen had commenced enlarging. The tumor 
was foimd to be raonocystic and so completely filling the abdomen 
that the patient had great inconvenience from distension. 

The removal of this tumor, which originated in the left ovary, was 
easy, as no adhesion or other obstacles were encountered. The patient 
recovered without experiencing any untoward symptoms. 

The tumor was composed of a single cyst, of which the wall was 
thin over about three-fourths of its circumference and easily ruptured. 
At the bottom or pedicular portion, involving about one-fourth of 
the inner surface, was a dense mass of areolar tissue literally filled 
with pieces of bone. The greater number of these i)ieces were cyl- 
indrical, from half an inch to two inches in length, and varying 
from an eighth to a quarter of an inch in thickness. They seemed 
to be imbedded in loose cellular tissue, were not attached to each 
other, and were easily removed by the finger. Other masses of bone, 
made up of alveolae, were not unlike the maxillary processes, and 
varied in length.from one to two inches, and in width from one- third 
to one-half inch. They resembled honeycomb, and were quite firmly 
attached to the cyst wall. The microscope showed their structure to 
be that of true bony tissue. This mass was covered by a tegumentary 
membrane to which was attached more than a hundred imperfect in- 
cisor teeth, distributed over the whole surface, their adhesions being 
so slight that they could easily be scraped from the surface with the 
finger. These dental bodies were all about the same size and con- 
sisted merely of the crown ; but the enamel and dentine seemed per- 
fect. They had no connection whatever with the bony tissue. In- 
terspersed among these teeth was a dense crop of blonde hair, aver- 
aging an inch in length. 

The fluid, of which there was about ten quarts, sp. gr. 1008, was 
clear, with a slight bluish tinge, and entirely devoid of tenacity or 
other colloid properties. I believed it to be perspiratory serum. 
There were also several ounces of yellow sebaceous fatty matter 
within the cyst. 

I should class this tumor among the true dermoid cysts of the 
ovary, and believe that it possessed none of the properties of the ordi- 
nary ovarian tumor. Its structure was much more complex than 
that of the two preceding tumors, but much less so than that to which 
I shall now call attention. 



570 OVARIAN TUMORS. 

Case IV. — Mrs. B., thirty-five years of age, the mother of four 
children, the last twenty months old, first noticed a tumor in the 
rio"ht iliac region nine years before the operation. It was then about 
the size of her fist. It had grown steadily but slowly until June 
19th, 1878, when it was extirpated. The growth did not seem to be 
influenced by pregnancy. She had borne three children from the 
time when the tumor was discovered to the time of its removal. 
Her health had been feeble for several years, but from the birth of 
her last child she had been confined to bed half of each day, and, for 
several weeks, all the time. The main inconvenience was from tlie 
w^eight and mobility of the tumor. When she was in the erect pos- 
ture it caused dysuria and rectal tenesmus ; when lying on either 
side it pressed upon the subjacent viscera and also dragged upon the 
upper side ; the only comfortable position was the dorsal. The pulse 
and temperature were decidedly and continuously above the normal 
standard. She was sleepless, had a very poor appetite, and was 
rapidly becoming emaciated. The above very brief history was given 
me by the attending physician, Dr. J. H. Low, of Brimfield, Illi- 
nois. 

The appearance of the abdomen was very singular. It was con- 
siderably distended; from its centre, including in fact the whole 
umbilical region, arose a round projection exactly resembling a ven- 
tral hernia, the umbilicus occupying its apex. It measured five 
inches in diameter, and protruded three and a half inches above the 
common level. It was fluctuating and dull upon percussion. On 
each side I could easily distinguish two other, apparently larger, cysts 
not projecting above the surface. Percussion over these elicited no 
resonance, but it was easy to detect fluctuation. The tumor could be 
moved pretty freely in all directions without traction upon any part 
of the abdominal walls. By external and internal manipulation I 
could trace the attachment of the mass to the right side of the pelvis 
and assure myself that it was not of uterine origin. It was clear that 
I had to deal w^ith a tumor made up, principally at least, of three 
cysts, and quite certainly originating in the right ovary, but it pre- 
sented so many unusual symptoms and appearances, that further 
diagnostic measures were necessary before I w^ould venture to remove 
it. After making preparations for its extirpation, the patient being 
fully etherized, I introduced a small trochar into the prominent cyst. 
A little sebaceous fat flowed through the canula, and at once made 
the diagnosis complete. The usual small incision exposed the pearly 
cyst and allowed me to evacuate the prominent sac of one quart of 



NATURE AND ANATOMY. 571 

thin, yellow fat. The other two cysts were drawn to the opening, 
and their contents, of a similar character, evacuated. By this time 
the rubber blanket was smeared with a sticky grease, the instruments 
had become slippery, and my fingers were encumbered with a mass 
of fat which had to be removed before I could proceed with the 
operation. The cysts were drawn through an incision about three 
inches long, and a short, slender pedicle, consisting of the right 
ovarian ligament, part of the broad ligament, and Fallopian tube, 
was brought up into the wounds, ligated, cut, and dropped into the 
pelvic cavity. The left ovary was healthy. As nothing had been 
allowed to pass into the peritoneal cavity the incision was then closed. 
It will have been seen by this description that no adhesions or other 
impediment hindered or complicated the operation. It was remark- 
able how extremely greasy everything employed in the operation 
became, and I had more trouble in cleansing the instruments from 
the grease than is usually experienced in getting rid of the blood and 
mucoid fluid of the common ovarian tumor. The patient had no 
untoward symptoms, seeming to me more like one recovering from 
the exhaustion and irritation in which I had found her than from the 
hazardous operation for the removal of an ovarian tumor. 

Before describing the tumor I wish to call attention to the fact 
that there was no serum evacuated during the operation ; no fluid but 
the soft fat was observed. The tumor proved to be a remarkable 
specimen of the true dermoid variety, nothing in its contents seem- 
ing to be of ovarian origin. The cyst wall was thin, but of firm 
structure, and divided into three compartments of about equal di- 
mensions. The septa were complete, and of the same consistence and 
density as the external walL At the base of the tumor the sac was 
more dense and firm than elsewhere. The peculiar formations con- 
tained in each cyst were so nearly alike that a description of the con- 
tents of one will suffice for each of the other two. 

On opening the cysts each was found to contain a mass of matted 
hair, the size of a lemon, thoroughly supplied with the same fatty 
substance that had been evacuated from the tumor. One of these 
rolls of hair was red, another blonde, and the other gray. The 
patient's hair was dark brown. Some of this hair was twenty inches 
long, and it was all attached to tegumentary substance closely re- 
sembling the scalp. The dermic structure, which was about four 
inches across, rested upon a very uneven layer of adipose tissue an 
inch thick. By the side of the dermic patch, and not covered by it, 
was a loose layer of areolar tissue, an inch and a half thick, contain- 



572 OVARIAN TUMORS. 

ing bones in a great variety of shapes, — scales, round bones an incli 
or more in length, alveolar nodules, etc. Upon- the surface of this 
part of the tumor in each cyst was a half-arch of teeth the shape of 
one-half the superior maxilla. In one cyst the crowns of the teeth 
projected above the surface, while in the other two they were thinly 
covered by tissue so soft that it could be pinched off by the thumb 
and finger. The teeth were not attached to the subjacent bones, but 
were simply imbedded in the loose mass. The teeth in each segment 
verv perfectly represented, respectively, an incisor and three molars, 
each having three well-marked fangs. One of the molars in each row 
stronglv resembled the wisdom tooth. The perfection of their forma- 
tion will be recognized in the specimens which I submit for your 
examination. The crown with the enamel and eminences, the main 
body, and roots are as distinctly marked as if they had been removed 
from alveolar cavities. 

Before leaving the description of the tumors and their removal, I 
would call your attention to the great simplicity of the operation and 
the fortunate recovery of all the patients, no adhesions or other com- 
plications having existed. 

Now what is a dermoid tumor? This name is given to a cyst 
formed anywhere in the body, the internal or lining membrane of 
which is in part or wholly tegumentary in structure. As now un- 
derstood, the presence of this condition alone would justify this 
nomenclature. The formation seems to be no less an error of struc- 
ture than location. Lebert, Paget, Virchow, and most other modern 
pathologists agree that the dermic tissue thus located is essentially the 
same in structure as true skin. The products are all the same, hair, 
sebaceous fat, and perspiratory fluid. In many of these tumors we 
find subcutaneous adipose tissue very perfectly formed. Less con- 
stantly, teeth, bone, muscular, nervous, and even brain tissues. These 
latter, except the teeth, in some instances, are found either beneath 
the dermic membrane or beneath the portion of the internal surface 
not lined by this cutaneous substance. 

My experience shows that the dermic tissue and its products char- 
acterize one variety of these formations, as in Cases II and III. 
These constituents are sometimes found alone, and may tlien be re- 
garded as indicative of a more simple formation, while the addition 
of bone, muscle, etc., constitute a more complex order of tumor rep- 
resented by Case IV. The bone and muscle, however, are never 
found in a tumor of this kind without the dermic membrane, its 
essential glands, and their products. Another thing quite apparent 



NATURE AND ANATOMY. 673 

is that the skin and its appendages are not only constantly present, 
but comparatively perfect in their organization. The teeth, which 
are very closely associated in embryonic metamorphosis with the 
formation of the skin, stand next; many being quite perfect in their 
structure. The bony, muscular, and nervous structures, although 
complete in their texture and formation, are never developed into 
complete organs. I am aware that cases have been recorded, — as for 
instance by Blumbach and Rokitansky, — that would seem to be at 
variance with this assertion ; but the bones in these cases lacked the 
completeness in structure necessary to entitle them to be classified 
with any of the bones in the human skeleton. When some or all of 
these structures, together with the products of the dermic tissue, con- 
stitute all the contents of the cyst, the specimen should be regarded 
as a simple dermic tumor, even when formed in the ovary, the fact 
of its having found a lodgment in that organ being an accidental 
rather than a necessary condition. When, however, it exists in the 
ovary, and with these substances there is found the colloid or mucoid 
fluid characteristic of the ordinary ovarian tumor, it is not merely a 
dermoid, but an ovarian dermoid tumor. It is a mixed neoplasm, a 
morbid development of the ovarian follicles in connection with the 
congenital dermoid. In my first case this was the character of the 
tumor ; and instances of this kind are recorded in the well-known 
books of Drs. Atlee, Peaslee, and Mr. Wells. The first variety, then, 
although often found in the ovary, differs in no essential particular 
from those found elsewhere, except in magnitude, and perhaps greater 
perfection of organized development. Possibly this last difference 
does not exist. 

When found in the ovary, either in the single or mixed form, the 
investing membrane seems to be the same in appearance and structure 
as in ordinary ovarian tumors ; and, when first exposed, it is often 
not easy, if at all possible, to distinguish between them until some of 
their contents are evacuated. 

To the more fluid products of the first variety of simple dermoid 
cysts, especially the secretion from the dermic tissue, such as the serous 
or perspiratory fluid, we must attribute the difference in the size of 
this form of tumor. The sebaceous product is also sometimes quite 
bulky, as seen in Case IV; but when the sudoriparous glands are 
numerous and active, the amount of watery fluid is sometimes enor- 
mous, and consequently the tumor grows to be very large, as may be 
specially noted in the second case. In such instances, from causes 
which are not appreciated, the sudoriparous glands seem suddenly to 



574 OVARIAN TUMORS. 

acquire great functional activity, and bv pouring into the tumor a 
large supply of fluid make it grow with great rapidity. 

As there was no appreciable amount of serum in Case IT. the sac 
beino; filled with the sebaceous matter, it is easily understood why the 
tumor was a lono- time in attaining the dimensions it finally acquired. 
The solid contents of these tumors, as far as I can learn, do not grow 
to a sufficient extent to give them any great bulk, and consequently, 
when situated in the ovary, such a tumor, apart from its fluid con- 
tents, would hardly require extirpation. 

The compound variety, or ovarian dermoid, would be likely to 
grow to a great size in consequence of the accumulation of the colloid 
secretion, just as they would if the dermoid element did not exist. 
By consulting the literature of the subject, I am led to the conclusion 
that the dermoid and colloid contents of these compound cysts are 
usually contained in different compartments of the tumor. This was 
notablv the case in some of Mr. Wells's specimens. 

There are one or two facts which may have some bearing upon the 
production and development of these tumors: The dermic membrane 
is always superficial with reference to the inner surface of the tumor; 
the hair always, and the teeth often, grow from its surface; while 
the bone and other tissues are situated below it, but not always im- 
mediately under it. In my fourth specimen the bone was imbedded 
in a mass of cellular substance by the side of the cutaneous layer, 
giving me the idea that it belonged to a blastodermic formation deeper 
than the tegumentary portion of the surface. 

The question here naturally presents itself: Whether the simpler 
forms of these dermoid cysts, in which the dermoid structure, with 
hair, fat, and serum are found without any of the deeper tissues, are 
tumors in the process of development into the more complicated va- 
riet^'? I think not, and belie re that each tumor receives during its 
embryonic state all the elements of formation it is capable of produc- 
ing; that the trophic qualities imparted to it then definitely limit its 
possibilities. If so, it necessarily follows that the tumor, containing 
all the variety of structure ever found in them, should manifest these 
qualities and structures without gradation of growth, and possess from 
the beginning the complex qualities found in advanced periods of 
life. 

Theories of their Origin. 

The theories devised to explain the origin and development of 
ovarian dermoid tumors represent, with some degree of exactness, the 
physiology of the times in which they originated. In the earlier ages 



NATURE AND ANATOMY. 575 

of medicine, physiology was the creature of imagination. Definite 
knowledge of the internal organs was wholly wanting; if possible, 
even less was known of their functions. Pathology also rested upon 
the same unsubstantial basis. As a consequence, the theories of the 
origin and development of these curious growths were all vague and 
imaginary. In the latest and most plausible explanation yet offered, 
we have the results of the present highly cultivated science of physi- 
ology; and if not absolutely true, there can be fewer rational and 
scientific objections opposed to it than to any of its predecessors. 

It is not my present purpose to do more than give a very cursory 
view of some of the most prominent theories which have at different 
ages been presented to, and accepted by, a large portion of the pro- 
fession at the time they were promulgated. I will classify the theo- 
ries under three divisions : I. Those originating in the imagination 
alone without any scientific foundation. II. Those w^hich have for 
their basis the superstitions of the times in which they originated, 
and of the people by whom they were entertained. III. The scien- 
tific theories. 

I. The most ancient of the imaginative theories is, I believe, at- 
tributed to Aristotle. It taught that the dermoid products of these 
tumors — as the hair, teeth, etc. — had been swallowed and transmitted 
in some unknown manner to the localities occupied by them. This 
idea is a good match for many of the ingenious vagaries of that wise 
man. 

Belief in virginal pregnancy supplied the basis of another and ex- 
tensively prevalent theory. It assumed several forms. One was the 
abstract possibility of a virgin becoming impregnated without sexual 
intercourse, or true parthogenesis. Another was that the ovaries pos- 
sessed properties that enabled them to produce, to a limited extent, 
the organized bodies resembling the parts of a foetus; or, again, that 
certain unsatisfied sexual longings of an isolated woman might stimu- 
late the ovaries to imperfect generative processes. 

Still another was that certain individuals possessed a sort of ovario- 
cystic diathesis which took this direction. 

It is easy to see that these vagaries — for they ought not to be dig- 
nified by the term theories — had no physiological basis and could be 
the products of imagination alone. 

II. The superstition of mediaeval times gave rise to the theory 
that these tumors were visitations of Providence upon the subjects of 
them on account of particular sins. The infliction of this punishment 
upon males as well as females showed Providence to be no respecter 



576 OVARIAN TUMORS. 

of persons. One man had a pregnancy in the thigh because he laughed 
at his wife in her suffering during labor. It is said that the products 
of these tumors were sometimes baptized in the hope of avoiding the 
perdition in which they would be involved without such a ceremony. 
Hence, it seemed that the priests believed in their own invention, 
and that the theory was not a mere trick with which they tried to 
practice upon the credulity and ignorance of the people. 

III. As the knowledge of physiology advanced somewhat among 
the profession, the theories became more rational, and the possibility 
of natural causes was employed to explain the occurrence of these 
singular tumors. 

They were regarded by many as ovarian pregnancy, in w^hich the 
formation of the foetus was imperfect, or, after having undergone 
development, the foetus had become disintegrated, and the skin, bones, 
and teeth being more difficult of destruction, had withstood decom- 
position and remained in the sac. Another theory accounted for 
their peculiarities by supposing that the ovum had become blighted 
after having been developed to a certain extent. 

Some one else has propagated the doctrine of inclusion, or of a 
foetus in foetu, believing that somehow one ovum had become en- 
gulphed in the organization of the other, and on account of the na- 
ture of its nidus could not attain to complete organization or devel- 
opment. 

Still later, plastic heterology and heterotopy were supposed to 
afford a more rational explanation of their production. According 
to this theory, the origin of these tumors in any part of the body is 
no more wonderful than the growth of other forms of heterologous 
tumors in the same localities. 

In the light of the patient physiological research of our own day, 
and especially from the revelations of the microscope, a theory of 
these curious tumors has been developed, which I regard by far the 
most satisfactory and scientific. 

This theory is based upon a supposition which is at least physio- 
logically plausible. It may be stated thus : 

In the early period of ovulation or embryonic development, by 
some accident or imperfection of formation, an indentation of the 
blastoderm is produced. In the wonderful trophic energy of that 
period the minute depression is inclosed by the approximation of its 
blastodermic margin and becomes an isolated cavity, and the growth 
and perfection of the embryo are accomplished notwithstanding this 
early accident to the integrity of its envelope. The depression thus 



NATURE AND ANATOMY. 577 

formed involves, perhaps, all the layers of the blastodermic mem- 
brane, but the external layer becomes the lining membrane of the 
cavity, and is completely cut off from the rest of the blastodermic 
surface and invaginated with all its essential structures and processes 
of organization ; all its products, therefore, must be retained in the 
cavity. The contents of this cavity correspond in miniature with 
what the formation might have been if the displacement had not 
occurred. In the further development of the embryo the portion of 
the blastoderm covering this adventitious cavity develops its tissues 
and organs in the ordinary way, and thus incloses it in the body by 
the structures usually found to cover it. The internal layer of the 
blastoderm is doubtless also displaced, but it is not isolated, and con- 
sequently its products are never found inside the tumor. Therefore, 
in instances where the dermoid patch occupies any of the mucous 
cavities, the neoplasm will always be found external to the mucous 
membrane. This theory serves to explain why these hairy tumors 
are found in the foetus, child, virgin, matron, or male, and with equal 
plausibility why they may exist in any part of the body. 

Dr. Pauly, in an excellent paper in the American Journal of 
Obstetrics, expresses a doubt whether they exist more frequently in 
the ovary than elsewhere, notwithstanding the generally received 
opinion that this is the case, and at present it cannot be asserted that 
they are not as common in the male as in the female. This theory 
would certainly not furnish us with reasons for their occurrence more 
frequently in woman than in man. 

If nothing unusual happens the adventitious sac grows with the 
individual in whom it is situated, and perhaps attains maturity as the 
same character of organs mature elsewhere. The sac itself continues 
to increase in size, because of the constant secretion of the glands of 
the dermic structure. Growth from this cause would probably be 
slow if the activity of the tegumentary glands were not preternatu- 
rally quickened by morbific causes. When situated in the ovary, 
however, the conditions naturally calculated to impart an impetus, 
exclusive of what is termed pathological states, exist. Hence in 
them they grow more rapidly and larger than in other places or 
organs. The fluctuation of nerve force, circulatory supply, and 
nutritional conditions which take place in the ovaries in consequence 
of the processes of menstruation, sexual excitement, and the varied 
states of generation, disturb the states of these otherwise nearly sta- 
tionary neoplasms. 

37 



578 OVARIAN TUMORS. 

These reasons would lead us to expect the dermoids situated in the 
ovaries to become large and to grow more rapidly than in any other 
organ or locality. When situated in these bodies their progress is 
usually tardy until the age of puberty is reached. At this time the 
tumor is likely to be influenced by the increased nervous and vascular 
activity assumed by the ovary, and thenceforward they manifestly 
possess all the conditions necessary to cause copious dermic secretions. 
In the ovaries, also, their growth is more likely to be influenced by 
the morbid impressions to which these organs are more frequently 
subjected than almost any other part or organ of the body. They 
are also doubtless especially stimulated by the occurrence of the con- 
ditions which give rise to the colloid tumors. For in connection 
with this form of tumor they are generally found to have assumed 
great proportions. 

The condition imparted to dermoid tumors by the ovaries would 
almost necessarily lead to their discovery during the lifetime of the 
patient, and thus favor the idea that they are more frequently located 
in these organs. Situated in organs of more unvarying functions 
they would be likely to remain dormant, and never attain dimensions 
that would cause them to be discovered ; consequently they are over- 
looked in the general statistics on the subject. 

Aftep ovarian tumors have been developed to a certain extent 
they become subject to diseases and accidents, and thus play an im- 
portant part in the sanitary conditions of patients in whom they 
exist. Inflammation attacks them, and causes ulceration in their 
walls so as even to perforate them, making a communication between 
the cavities of contiguous cysts, or with the peritoneal cavity. With- 
out perforating the walls of the tumor, the ulceration may produce a 
good deal of pus, which is mingled with the other contents of the 
cyst in which it occurs. General inflammation of its walls may pro- 
ceed to a fatally exhaustive extent, or spread to the peritoneum, and 
thus indirectly cause death. Gangrene may also result, which may 
be confined to the cavity of some of the cysts, and induce a putrid, 
ofiensive state of the contents, or perforate the dividing partitions, 
and thus make a communication between cysts, or open them into the 
peritoneal cavity. The walls may also rupture from distension in 
consequence of their becoming attenuated, or as the efi^ect of a violent 
stroke or fall, or other shock, and the contents escape into the perito- 
neal cavity. By means of ulcerative communication with the Fallo- 
pian tubes the fluid sometimes escapes. Adhesion to the walls of the 
abdomen from inflammation and ulceration through the parts thus 



NATURE AND ANATOMY. 579 

agglomerated sometimes results, and the fluid so discharged. Inflam- 
mation also causes adhesion at various parts. The fibrin eff'used 
glues it to the surrounding parts, — the abdominal walls, the intes- 
tinal canal, bladder, and other viscera. Slight inflammation is sup- 
posed to increase the effusion in their cavities, and cause them to grow 
very rapidly. Inflammation, also, sometimes, no doubt, causes oblit- 
eration of the cavity from adhesion of the walls. This is more fre- 
quently the case when it results from external causes, as blows, tap- 
ping, pressure, injection, etc. Now, it hardly ever happens that these 
diseased conditions and accidents of the tumors fail to produce their 
effects upon the health of the patient. No doubt but that death 
occurs from extensive disease in the sac, without any organ being 
directly involved. A large production of pus would exhaust the 
patient ; gangrene, to a large extent, would cause death, as extensive 
gangrene of unimportant organs generally does. But an extension 
of disease to the peritoneum and surrounding viscera, or by the effu- 
sion of the acrid contents of a diseased cyst, is more likely to be the 
mode of progress to constitutional disturbances inaugurated by in- 
flammation in the tumors. 

When the tumor bursts, and its contents are effused into the peri- 
toneal cavity, the peritoneum seldom escapes without inflammation; 
but the degree will depend upon the nature of its contents. If they 
are not vitiated, but consist of the bland albuminous fluid found there 
ordinarily, it is very slight indeed, and lasts for a very short time 
only. But should pus, or the ichor of decomposition, be mingled 
with it, we should be prepared to expect serious if not fatal results. 

I once had an opportunity of observing the progress of a case for 
several months, where this rupture and eftusion were frequently re- 
peated. About every three weeks the woman would attain to a large 
size, and a well-defined large cyst could be felt filling up the whole 
abdomen and distending it greatly, when suddenly, without premoni- 
tion or apparent cause, the cyst would give way, the swelling would 
become more diffuse, fluctuation more obvious, and the cyst could 
be no longer defined by the touch ; slight fever and some tenderness 
of the abdomen would last for two or three days, when copious per- 
spiration and diuresis would evacuate the fluid in a few days more. 
After this process was completed, the abdomen would be lank, and a 
small cyst could be felt rising up from the left ilium ; it would in- 
crease and burst at the end of three weeks, as the other had done be- 
fore. I saw the patient frequently while this process was repeated 
six or seven times, when, as she would not submit to the operative 



580 OVARIAN TUMORS. 

procedure which I insisted upon, I was dismissed, and an irregular 
practitioner, who was sure he could cure her, installed in my place. 
Not long (perhaps three months) after I was discharged she died from 
the inflammation resulting from one of these. effusions, probably be- 
cause the contents of the cyst had become vitiated by inflammation. 

But these growths may produce a pathological condition of the 
system without becoming themselves the seat of disease, by the great 
size they may attain mechanically interfering with the functions of 
the pelvic and abdominal viscera. Before rising out of the pelvis it 
may displace the uterus, and cause inconvenience from this effect; it 
may press upon and obstruct the rectum, bladder, and urethra, or 
upon the iliac veins, causing obstruction to the flow of blood, and 
varicose veins in the legs, phlebitis or phlegmasia dolens ; or, pressing 
upon the nerves, cause neuralgic pains in the limbs, hips, etc. It is 
plain that such pathological effects, when induced, would be serious, 
in proportion with the greater or less impaction in the pelvis by its 
continued growth. Ordinarily, these inconveniences do not prove 
very embarrassing to the functions of the important vital organs, but 
sometimes the case is far otherwise, and life is very much shortened 
and health rendered miserable. As it rises into the abdomen, these 
mechanical troubles are apt to be lessened ; and as the room is com- 
paratively so great in that cavity, quite a while elapses before any 
great disturbance results from mechanical pressure. After awhile, 
however, the abdominal muscles are distended beyond convenient 
size, and the tumor is strongly pressed among the viscera. The kid- 
neys, liver, stomach, intestinal tube, in fact, all the abdominal organs, 
may become the subject of great and even fatal pressure. In many 
instances, however, enormous size is attained before fatal damage re- 
sults. One hundred and fifty pints of fluid have been taken at a single 
tapping. A much less amount, in most cases, w^ould produce very 
grave results by pressure. When the growth is rapid, its mechanical 
effects will be more distressing; and, on the contrary, the organs 
accommodate themselves to a great deal more pressure if gradually 
brought about. 

Besides the inflammatory changes that take place in the tumor, 
chronic degeneration is occasionally observed. Deposits of earthy 
substances in the walls, bony spiculse, etc., are the most frequent. 
Small tumors, containing solid material, are more commonly thus 
affected. 

The modes of termination are worthy of some consideration. Many 
cases, in consequence of a low grade of vitality, last through a great 



TERMINATION. 581 

many years without materially influencing the general health, and up 
to the death of the patient, at an advanced age, when large, prove to 
be nothing more than an inconvenient burden, and when small not 
the cause of even this kind of trouble. Others, in consequence of 
their bounteous vascular supply and energetic vitality, bring about 
fatal conditions of the abdominal organs in a few months. Sponta- 
neously favorable terminations are so rare that we can base no calcu- 
lation upon them. Perhaps rupture of the sac into the peritoneal 
cavity, collapse, and adhesion of its walls, is the most common an<i 
favorable spontaneous termination. After the rupture, in cases where 
cure follows, it is probable that the opening in the sac continues, and as 
a permanent fistula from the cyst into the peritoneum, places the fluid 
in contact with a more active absorbing surface, until, by the elasticity 
of its walls, it contracts to annihilation, or, at the first shock of the rup- 
ture, inflammation is originated that causes an obliteration of the 
cavity of the sac. Dr. Simpson speaks of instances of evacuation 
through the vagina. The same thing might occur in connection with 
the bladder or alimentary canal. I have already spoken of adhesion 
to and rupture through the walls of the abdomen, and consequent 
recovery. Inflammation in its proper tissues, no doubt, sometimes 
arrests the development of and obliterates the tumor without mate- 
rially aifecting the patient's general health. It is not improbable 
that other circumstances with which we are not acquainted may like- 
wise operate to cause the arrest and cure of them, inasmuch as they 
unquestionably do sometimes disappear in an unaccountable manner. 

The local pressure interfering with the functions of the bladder 
and rectum may induce complicating diseases that lead to death, and 
consequently cause death before the tumor is very largely developed. 
Inflammation will spread upon these organs to their more vital con- 
nections and relative organs ; or, by interfering with excretion from 
the bowels or bladder, produce disease of the blood, and thus grad- 
ually undermine the health of the patient. 

After the tumor has ascended into and greatly distended the ab- 
dominal cavity, pressure upon the viscera will sometimes produce 
disastrous terminations. The stomach is crowded into a very small 
space, food can be taken but sparingly, and is often rejected before 
digestion is completed. The vascular supply of this organ is cramped, 
and its secretions vitiated and embarrassed, and in this way digestion 
is interfered with, the appetite destroyed, and loathing of food takes 
its place. 

Pressure upon the vena porta embarrasses the secretion of the liver. 



682 OVARIAN TUMORS. 

Pressure upon the ductus choledochus, gall-bladder, and duodenum 
stops the excretion of bile ; it is dammed back upon the gland, ab- 
sorbed, and thrown into the blood to poison the nervous centres. 

There is no doubt, also, that the general compression of the organs, 
by pressure upon the chyle absorbents, prevents that fluid from pass- 
ing as freely as usual into the blood, and thus by degrees starves the 
patient. But probably no more disastrous effects of the pressure of 
the tumor in the abdomen is noticed than such as is produced 
through the kidneys. Pressure upon the emulgent veins causes con- 
gestion of the kidney, retention of urea and other matters that should 
be excreted, and drains oif the albumen with the urine, until the 
blood becomes thinned enough to infiltrate into the cellular tissue 
in the form of oedema of the extremities, or into the peritoneal 
cavity, giving rise to ascites. But this is not the worst mischief, 
perhaps, caused by the pressure on the kidneys. The poisoning of 
the blood with urea, and its effect on the nerves and vital organs, is 
too well known to require more than inere mention to suggest the 
rapidly fatal tendencies w^hich result from it. 

Inflammation in any of the important abdominal organs may be 
caused by the pressure, which will terminate fatally m a greater or 
less time, owing to its acuteness or slowness of progress. It will be 
seen by the above that ovarian disease usually terminates by induc- 
ing a long train of distressing constitutional symptoms. They are 
not uniform, some persons suffering from one mode of complication 
and some from another ; but nearly all are pretty sure to experience 
those terrible sufferings which are connected with secondary disturb- 
ances in the vital organs. 

The presence of the tumor, when not large enough to press upon 
the organs sufficiently to do very much damage, sometimes leads to 
copious dropsical effusion in the peritoneal cavity. This is, at least 
sometimes, the result of an influence exerted upon the peritoneum, 
causing it to secrete more than an ordinary amount of serum. 

One case upon which I operated and evacuated a large amount of 
serum from the peritoneal sac recovered completely from the opera- 
tion, but died about two months after from extreme abdominal dis- 
tension, in spite of alteratives and diuretics. 

Causes. 

It is extremely doubtful whether there is anything in the general 
condition of the patients that predisposes to the development of 
ovarian tumors. There is quite a disposition, however, with certain 



CAUSES. 583 

authors, as will be apparent to any careful reader, to trace most 
chronic enlargements to scrofulous taint in the system ; and these 
gentlemen express the belief that scrofula predisposes to ovarian dis- 
ease. I think we may very safely conclude that in the function of 
menstruation we have a predisposing cause of ovarian disease. It is 
true that ovarian tumors have been found in the ovaria of infants and 
foetuses, and very aged females ; but this probably is as rare an ex- 
ception to the general rule — that they occur during menstrual life — 
as the occurrence of menstruation in infancy and old age. Some cir- 
cumstances connected with menstrual life appear also to increase the 
predisposition. Sixty-one per cent., according to Dr. West, of the 
patients were married, while only twenty-nine had never been mar- 
ried. After making allowances for the greater proportion of women 
at twenty-five who are married, I think we may fairly infer that 
marriage adds somewhat to the chances of the occurrence of ovarian 
dropsy. 

That patients who are the subjects of this disease should be less 
likely to hav^e children than those in whom ovulation is more perfect 
and complete, will not, I think, justify us in setting down sterility as 
the cause of it in any way, but it is more probably connected as an 
effect. During menstrual life the. most obnoxious time is between 
the ages of twenty-five and forty, the time when the sexual functions 
are exercised with more activity than any other. 

Unhealthy menstruation seems to be more commonly coincident 
with it than healthy. Abortions and premature labor are so likewise. 

We should attach sufficient importance to the fact that it occurs in 
unmarried persons as often as twenty-nine per cent. This induces 
Dr. West to remark, that ^' it occurs in the unmarried oftener than 
any other organic disease of the sexual organs." 

The exciting or proximate causes are such as excite the ovaria 
and induce abortive efforts at ovulation. What does so we are not 
able to say with certainty. 

Inflammation of a low grade, and somewhat chronic duration, 
might cause induration or thickening of the indusium, so that it 
would not yield to the upheaving pressure of the ovisac and permit 
dehiscence. 

The probabilities, I think, are in favor of this mode of merging 
a healthy into an unhealthy accumulation. When once thus com- 
menced, the stimulus of increased incretion of fluid would carry on a 
kind of hypertrophy in the involucra that would permit of a further 
enlargement. Now the local circumstances that are regarded as the 



584 OVARIAN TUMORS. 

causes of the disease would favor the occurrence of inflammation, and 
are very frequently attended with some of the symptoms of it. The 
ovary and uterus, during each menstrual period, are often attended 
with pain in the ovarian region of just such a character as we would 
expect to indicate inflammation. This ovarian pain is present in 
other excited conditions of the sexual organs also, thus showing that 
they are often the focus of painful vascular turgescence, if not inflam- 
mation. While inflammation is probably the cause of the beginning 
of the development of ovarian tumors, it does not seem necessary to 
their continued development, as the accumulation of fluid in a shut 
cavitv, with a secreting internal surface, is a matter of course, and 
the limit of its amount, for the most part, does not depend upon any- 
thing but the capacity of the involucra to grow, until interrupted by 
external circumstances. 

Although inflammation may, in most cases, be the cause of the 
toughness of the covering to the ovary, which prevents the escape of 
the ovum, this condition may result from some other local circum- 
stance. Congenital formation may be such as to permit the invo- 
lucra to increase as fast as the demand for more room becomes neces- 
sary. 

Prognosis. 

Our knowledge with regard to the prognosis is unfortunately too 
definite. There is no need of much conjecture with reference to this 
matter; the termination is too frequently demonstrated. In arriving 
at prognosis with reference to any disease, we ought to consider 
whether its ordinary course is, after a time, to a termination in health, 
as is the case with many diseases^ or, there being no such favorable 
tendency, what are the probabilities of a cure. Unfortunately, there 
is almost no tendency to spontaneous recovery in ovarian dropsy; 
probably not two per cent, but would, after a longer or shorter time, 
terminate in the death of the patient. While this is the case, it does 
not properly represent the value of a life threatened by this aflection. 
Some patients live a great many years in camparative comfort; but, 
by large odds, the case is generally very different, — only a few years 
being sufficient to finish the course in a downward direction. The 
average duration of life is about three years from the time it is first 
perceived. 

We should carefully examine every individual case with reference 
to its orvn peculiarities, its nature, and the character and condition of 
the patient. Is the disease simple, or a compound of cyst and solid, 
polycystic or monocystic? The monocystic is very much more favor- 



PROGNOSIS. 585 

able for treatment, and terminates in spontaneous recovery oftener 
than the polycystic. The duration of life is greater, also, in the 
monocystic. If several years have elapsed since the patient was 
aware of the presence of the tumor, it will probably continue to in- 
crease slowly, unless, as is sometimes the case, more activity has lately 
been observed, so that a tumor that had formerly grown very slowly, 
and required a number of years to acquire half its size, has grown 
the rest in a few months. In this last, there is every probability of 
a rapidly fatal course. Again, if the patient has not known any in- 
crease of size until within a few months past, and yet is quite large, 
the prognosis is bad. Our prognosis is influenced by age to a con- 
siderable extent; occurring in young persons, it is more likely to 
advance rapidly than in old ones. A woman at forty is not apt to de- 
velop an ovarian dropsy so rapidly as one at from sixteen to twenty. 

Ovarian dropsy will adv^ance less rapidly after menstruation ceases 
than before, and the earlier in menstrual life the more rapidly it will 
advance. The prognosis, as a general thing, therefore, is worse in 
the young than the old. If we should decide the question by age 
how long will she live, we should speak more favorably to the woman 
advanced in years. 

The inflammation, the pressure upon the rectum, bladder, stomach, 
bowels, and, above all, the kidneys, the nervous system, the vascular 
system, nutrition, as shown by the signs of emaciation or otherwise, 
should all be carefully scrutinized. 

Diagnosis. 

The diagnosis of ovarian tumors, when tolerably large, and not 
complicated with more than ordinarily embarrassing circunastances, 
is not difficult; but instances do occur where the matter is far other- 
wise, and a positive opinion cannot, with propriety, be given. 

General Remarhs on Diagnosis of Ovarian Tumors Generally. 

The history will afford us in many cases, however, very valuable 
aid in arriving at correct conclusions. It is now pretty well deter- 
mined that the average duration is about three years. In this time 
it will spontaneously produce fatal effects, by great size and extreme 
distension, and the resulting damage. This is longer than pregnancy 
lasts, and a shorter time than is required for solid fibrous growths to 
reach the same results. The age at which they are most likely to 
occur is an average of twenty-six years, according to Mr. Brown, 
although they may occur at any time during the active condition of 



586 OVARIAN TUMORS. 

the sexual functions, while the ovaria are subject to menstrual con- 
gestions and their effects. Quite a large number of cases make their 
first appearance in early menstrual life. I knew one in which the 
beginning of the tumor must have been simultaneous with, if not 
antecedent to, the commencement of the function of menstruation. 
Fibrous growths of the uterus are not likely to begin so soon. Their 
increase after being first observed is comparatively rapid, more so in 
the young than those somewhat advanced in age. They are not usu- 
ally attended with pain in their own proper substance; this is not 
always true, for the congestion and hyperexcitement may be attended 
with pain and soreness. The functional disturbance, in their early 
stages, occurs in the pelvic viscera; first, on account of pressure, such 
as tenesmus, dysuria, dragging, or weight in the pelvis ; and secondly, 
imperfect menstruation. Sometimes the menses are suppressed, scanty, 
and painful, but often no deviation is observed. The main thing in 
the history of the case, in this respect, is to remember that the symp- 
toms point in the beginning to trouble in the pelvis. It is generally, 
or at least sometimes, stated that the tumor rises from one iliac region 
and continues to occupy one side for some time. This, I think, is 
the exception to the rule, and, by Dr. Frederick Bird, is considered 
an evidence of adhesion. When large enough to overcome the sup- 
port of their peritoneal envelope, they fall into the cul-de-sac of 
Douglas, and, as they grow, come up in front of the promontory of 
the sacrum, until large enough to be felt above the pubis, having 
their point of support in the hollow of the sacrum, instead of one of 
the iliac fossae. The patient will usually speak of it as a lump, in- 
stead of saying that she is swollen, as in pregnancy. She has w^atched 
it coming up out of the pelvis, and not starting from above or from 
one side, and encroaching upon the abdomen from either of those 
directions. 

The knowledge derived by physical examination is the most valu- 
able; and while the modes of procedure are the same, and applicable 
to all stages of growth and enlargements of the tumor, we will be 
able better to describe and understand them, as made use of for one 
that has arisen from the pelvis, and pretty thoroughly filled the 
abdominal cavity, — a tumor that has become obvious, and from which 
our patient is solicitous of being relieved. 

The means afforded us for physical examination are : 1st, palpa- 
tion ; 2d, percussion; 3(1, auscultation ; 4th, vaginal and rectal digital 
examination ; 5th, examination w^ith the sound or uterine probe. 
These may be used separately, or combined in any given case ; some 



DIAGNOSIS. 587 

being more valuable in some cases, and others in different ones. 
Exploring needles, chemical tests, and the microscope may also be 
used to great advantage. Palpation is of very little use while the 
tumor is still in the pelvis, except in conjunction with the vaginal 
touch or the uterine probe ; as it rises in the abdomen, however, this 
process of examination comes into use independently. In this con- 
dition we can examine the consistence, size, shape, and mobility of 
the growth, and form some opinion as to its adhesion to the walls of 
the abdomen, and its primary attachments. 

In the ordinary condition of the contents of the abdomen the in- 
testines lie in contact with the anterior and lateral walls, except in 
the right and left hypochondria, where the liver, over a considerable 
space, and the spleen, a smaller, displace them. In consequence of 
this state of things, the resonance caused by the gas in the alimentary 
tube extends all over the anterior and lateral walls, save the above 
exceptions. Dulness upon percussion, therefore, indicates the presence 
of a tumor. The mesenteric attachments between the posterior wall 
of the abdomen and intestinal tube prevent them from being separated 
to any considerable extent; hence tumors occupying much space are 
apt to displace and get anterior to the latter. If the tumor springs 
from the pelvis this is particularly the case, as well from the above 
facts as the direction given to it by the axis of the superior strait ; 
thus it is with the gravid uterus, uterine fibrous growths, and ovarian 
enlargements. Growths from the pelvis, perhaps, more completely 
gain the anterior position than any other sort, unless it be such as are 
attached to the anterior wall originally. It may be observed, too, 
that it takes a larger growth to disengage itself from intestinal reso- 
nance when arising from the posterior wall than from any other 
situation in that cavity. 

By percussion we may make out the boundaries, positions, and, to 
some extent, attachment and contents of an abdominal tumor. We 
should begin at the pubis, and follow a line upward to the ensiform 
cartilage; by so doing we will ascertain the central perpendicular 
extent. A good plan is to make four or five perpendicular explora- 
tions of this kind each side of the median line, extending the whole 
length of the abdominal cavity. After this has been done we may 
proceed, by right angles to these lines, to examine the abdomen cross- 
wise, from its lower to its upper boundary. We will seldom miss any 
important growth by this mode of proceeding. If there is any doubt 
or obscurity, pressure in connection Avith percussion should be suffi- 
cient to bring out something of the flatness of sound from the spine. 



588 OVARIAN TUMORS. 

kidnevs, etc. If we discover any point of sufficiently defined dulness 
to impress us with the idea of a tumor, we should, by percussing ex- 
plorations, proceed from the point of greatest dulness to its circumfer- 
ence in every direction. In tliis way of examining, we will be able to 
trace it up the side to the hypochondriac regions down into the pelvis, 
or define it so perfectly as to decide what must be its place of origin. 
Another valuable method of employing palpation is to place one hand 
on each side of the abdomen, and press them strongly toward each other. 
If there is a tumor its resistance to their approximation will demonstrate 
its presence. Percussion and palpation will often enable us to deter- 
mine the contents of a tumor as to its solidity or fluidity. Placing 
the finger on one side of the tumor, while we percuss the other, if the 
contents are wholly fluid, a wave of liquid wdll be set in motion on 
the side struck, and traverse the space to the one of% the opposite ; it 
solid, of course nothing of this kind will take place, and the impulse 
wdll be given to the whole substance of the growth. Should the 
contents be fluid, separated by a number of partitions, the wave or 
fluctuation will be less distinct than in the one where no such division 
exists ; but in fact the ol:>scurity is so great that we will be at a loss 
by this management to decide whether the contents are solid or fluid. 
A slight variation of this combination of tact and percussion will 
often clear it up, however. When we wish to ascertain whether the 
fluid is contained in several cysts, we should place the pulp of the 
fingers of the left hand in the centre of the tumor, and then percuss 
w^ith those of the right, first very near, then gradually increase the 
distance between them, until we find a point at which the fluctuation 
becomes less distinct ; this is the margin of the cyst over which our 
left fingers are placed. Still keeping them in position, we percuss 
around in every direction, until we have made out the boundary and 
size of the cyst under examination, when we may move the fixed 
fingers to its margin, and commence the same process around this 
point. Proceeding in this way from one point in the abdomen to 
another, in most instances we maj' trace the outline of all the cysts 
superficially situated, and thus enumerate them, and learn their rela- 
tion and absolute size. If solid bodies, of whatever structure, are 
incorporated in the mass and superficially situated, they may be de- 
tected with their relative position, size, etc. 

After tapping, when the abdomen is lessened, its walls lax and 
soft, palpation, and percussion, singly or combined, become more 
demonstrative than before this operation. It not unfrequently is 
necessary, on account of the sensitiveness of the patient, when the 



DIAGNOSIS. 589 

tumor is small, and the abdominal muscles not much under con- 
trol of the will, to administer chloroform until unconsciousness is 
induced, and the influence should often be so profound as to abolish 
reflex sensibility. Palpation and percussion should both be prac- 
ticed ordinarily with the patient in the recumbent position on the 
back, with knees drawn up, shoulders elevated, and the abdomen 
stripped quite bare of covering ; in many instances, however, varia- 
tion of posture is indispensable to definite results, — the standing, 
prone, etc. Very little need be said in this place about auscultation, 
as it is only applicable to the diagnosis between it and pregnancy, 
and will be dwelt upon when I come to speak of that more particu- 
larly. Vaginal and rectal digital examinations in ovarian disease 
are proper, and should not be dispensed with. The pelvis should be 
carefully surveyed by this method. The attachments, consistence, and 
relations of the diseased mass to the various organs in this cavity 
should be carefully noted. The uterus, rectum, and bladder, so far 
as* practicable, ought to be examined with reference to their healthy 
condition, position, and involvement. Combined with external pal- 
pation, we may examine the tumor more thoroughly than with either 
one alone. Two fingers introduced into the vagina, and pressed 
firmly upward against it, will perceive any impulse imparted to the 
tumor above. With the left hand, if we press downward toward the 
pelvis, we may feel the motion of the diseased accumulation down- 
ward, and, if the sudden impulse of percussion is applied above, we 
may feel an impression from its contents ; if fluid, a wave or sense of 
fluctuation ; if solid, the deadened impulse always given in such 
cases. When the tumor is small, and occupies the posterior peri- 
toneal cul-de-sac, by introducing one finger in the rectum, and the 
other into the vagina, the tumor may be included between them, and 
thus examined with more accuracy than with either alone. 

Dr. Simpson has taught us how to extend our examinations into 
the uterus, so that our information in this direction is very materially 
increased by the use of the probe mounted upon a handle. Members 
of the profession who appreciate the labors of Dr. Simpson have, 
by consent, named the instrument, the improvements and uses of 
which he has so ably promulgated, ^'Simpson's sound." 

The sound may be introduced into the uterus, and varied in its 
direction, while we gently urge it forward to the extremity of the 
uterine cavity. The only obstacle a sound of the proper size will 
meet with in a uterus of ordinary size arises from want of correspond- 
ence with the direction of the cavity. The most simple and ready 



590 



OVARIAN TUMORS. 



revelation of the sound or probe is the direction and length of the 
uterine cavity. From this knowledge much valuable deduction may 
be drawn. But it is employed for determining the relation of the 
uterus to pelvic tumors, according to the ingenious directions of Dr. 
Simpson, very handily and to excellent purpose. While the sound 
is in the cavity of the uterus, this organ may be fixed by holding the 
instrument firmly in one position, or be moved in any direction, if 
not restrained by adhesion or accretional attachment to the diseased 
mass, or to some other organ. If the uterus be fixed, and the tumor 
moved by its side or from it, with the fingers introduced for the pur- 
pose, the motion w^ill be felt affecting the uterus through the attach- 




BOSTON. 

Aspirator. 



ments. On the other hand, if we watch the motion of the tumor 
with the fingers while the uterus is moved, the attachment or not will 
be determined, or the uterus may be moved in one direction and the 
tumor in another. In this way their attachments may be pretty cer- 
tainly diagnosticated. The sound may be employed in the uterus with 
one hand, while palpation on the abdominal surface is effected with 
the other ; and, if the uterus reaches above the pubis, the distance 
the probe is separated from the external hand, or its relation with 
the median line of the abdomen, or the main bulk of the growth, w411 
enable us to determine some interesting problems. The motion re- 
ceived by the sound from the pressure of the hand without, or vice 
versd, is of important significance, as will be more apparent as we 
advance. 

When, from all these sources of inquiry, we fail to get a suffi- 
ciently definite answer, there is still another physical means of diag- 



DIAGNOSIS. 591 

Dosis which we are justified in employing, viz., exploration. By 
means of an exploring needle, or aspirator, we can draw oif a small 
quantity of fluid ; it may be subjected to microscopic and chemical 
tests that will often enable us to determine the nature of the disease. 

Dr. J. Hughes Bennett, in a paper on " Ovarian Disease,'' in the 
Edinburgh 3Iedical and Surgical Journal, quoted by Mr. Brown, 
says, as the result of his microscopic '' examinations of different speci- 
mens of ovarian fluid, that the most constant characteristic of such 
fluid is its containing, in greater or less abundance, cells gorged with 
granules ; and, in addition, circumambient granules, having the same 
measurement as those encompassed by the cell-wall. At one time I 
considered the size of these granules (if they can properly be so 
called) was constant, but subsequent observations have convinced me 
of the incorrectness of this conclusion ; the size of the gorged cells 
and granules varies greatly, even in the fluids from different cysts of 
the same ovary." There can be no question but that the nature of 
the fluid contained in these cysts is, in all its essential features, pretty 
constantly the same in the early stages of progress ; but it is equally 
true that, as they grow large enough to be influenced by pressure or 
other external causes, their microscopic composition must vary. 

Although my opportunities for microscopic examination of ovarian 
fluid have been quite limited as compared to others, I cannot but 
express a decided belief in the conclusion arrived at by Dr. J. M. 
Drysdale. 

I have never found the ovarian cell described by Drysdale in any 
but ovarian fluid ; nor have I failed to find it in specimens that I 
knew to be fluid from an ovarian tumor. It is but fair to say, how- 
ever, so many of the best gynaecologists doubt the accuracy of his 
conclusions, that the question is far from being settled. 

The fluid drawn from the tumor is generally turbid and discolored, 
often chocolate color. When felt between the thumb and finger is 
sticky, and sometimes very tenacious and ropy. 

The granular cell revealed by the microscope, according to Drys- 
dale, is best exhibited in contrast with other pathological products 
contained in the sac, as given in the plate and description on pages 
458-59 of Ovarian Tumors, by Dr. W. L. Atlee. 

" On the Granular Cell found in Ovarian Fluid. 

" On placing a drop of the fluid removed from an ovarian cyst under 
the microscope, we usually find a number of granular cells, E, some 
free granular matter, c, and small oil-globules, b; and frequently, in 



592 OVARIAN TUMORS. 

additioD to these, epithelial cells of various forms, A, and crystals of 
cholesterin, D. These, together with blood -corpuscles, F, the inflam- 
matorv globules of Gluge, i, the pus-cell, G h, and disintegrated blood 
and other cells, mav all be sometimes seen floating in either a clear 
or a turbid fluid. 

" To find them all present in one specimen, however, is rare; more 
commonlv we can discover but three or four of them in the fluid. 
But no matterr what other cells may he present or absent ^ the cell ichich 
is almost invariably found in these fluids is the granular cell. 

"This granular cell, E, in ovarian fluid is generally round, but 
sometimes a little oval in form, is very delicate, transparent, and 
contains a number of fine granules, but no nucleus. The granules 
have a clear, well-defined outline. These cells differ greatly in size, 
but the structure is always the same. They may be seen as small as 
the one five-thousandth of an inch in diameter, and from this to the 
one two-thousandth of an inch. In some instances I have found 
them much larger, but the size most commonly met with is about 
that of a pus-cell.* 

" The addition of acetic acid causes the granules to become more 
distinct, while the. cell becomes more transparent. When ether is 
added, the granules become nearly transparent, but the appearance 
of the cell is not changed. 

" This granular cell may be distinguished from the pus-cell, lymph- 
corpuscle, white blood-cell, and other cells which resemble them, 
both by the appearance of the cell and by its behavior with acetic 
acid, 

'• The pus and other cells, G, which have just been named, have 
often a distinctly granular appearance; but the granules are not so 
clearly define<I as in the granular cell found in ovarian disease, owing 
to the partial opacity of these cells ; and, when the granular cell of 
ovarian disease and the pus-cell are placed together under the micro- 
scope, this difference is very apparent. In addition to the opacity 
of these cells, we frecjuently find their cell-wall appearing wrinkled 
rather than granular : and further, in the fresh state, they are often 
seen to contain a body resembling a nucleus. 

"■•' But if there is doubt as to the nature of the cell, the addition of 
acetic acid dispels it; for if it is a pus-cell, or any of the cells named 

* 'Bv comparing the drawing of the ovarian cell which accompanies this paper 
with one given in Dr. Atlee's work on Ovarian Tumors, it will be seen that I have 
omitted the three large dark cells which form the left of the group representing 
the ovarian cell in that drawing, and which are inaccurate. 



DIAGNOSIS. 593 

above, it will, on adding this acid, be seen to increase in size, become 
very transparent, and nuclei, varying in number from one to four, 
will become visible. (See G, pus-cell, before adding acid; and H, pus- 
cell, after adding acid.) Should the cell, however, be an ovarian 
granular cell, the addition of this acid will merely increase its trans- 
parency and show the granules more distinctly. 

*'The compound granular cell, i, the granule-cell of Paget and 
others, or inflammation-corpuscle of Gluge, is also occasionally present 
in these fluids, and might possibly be mistaken for the ovarian gran- 
ular cell; but it is not difficult to distinguish them from each other. 
Gluge's cell is usually much larger and more opaque than the ova- 
rian cell, and has the appearance of an aggregation of minute oil- 
globules, sometimes inclosed in a cell-wall, and at others deficient in 
this respect. The granules are coarser, and vary in size, while the 
granules of the ovarian cell are more uniform and very small. By 
comparing them in the drawing, these differences will be apparent. 
-Again, the behavior of these cells on the addition of ether will at 
once decide the question; for while the ovarian granular cell remains 
nearly unaffected by it, or, at most, has its granules made paler, the 
cell of Gluge loses its granular appearance, and sometimes entirely 
disappears through the solution of its contents by the ether. 

^'That the discovery of a granular cell in ovarian fluid is new I do 
not assert, as J. Hughes Bennett and other writers have described 
granular cells which they have seen in these fluids; but, with one 
exception, their description does not correspond with the ovarian 
granular ceil. Bennett, for instance [Ed. Med. and Surg. Journ.y 
vol. Ixv, p. 280, 1846), states that the granular cell which he saw 
exhibited a distinct nucleus on the addition of acetic acid, which is 
not the case with this. Other writers have described the cells which 
they found as pus and pyoid cells, and yet others confound them with 
the compound granular cell or inflammation globules. The excep- 
tion referred to above is found in Beale's description of the micro- 
scopic appearance of ovarian fluid.* He observes: 

"'The cells are composed of at least two distinct forms: 1. Small, 
delicate, transparent, and faintly granular cells, without the slightest 
appearance of a nucleus, some being somewhat larger, and others smaller, 
than a pus-corpuscle. 2. Large cells, often as much as the thousandth 
of an inch in diameter, but varying in size, of a dark color by trans- 
mitted, and white by reflected light. These, which have been termed 

* The Microscope in its Application to Practical Medicine. By Lionel S. Beale, 
M.B., F.R.S., etc. 3d edit., p. 179. 

38 



594 



OVA^RIAN TUMORS. 



" granular-corpuscles," " compound granular cells," " inflammation glob- 
ules," etc., are aggregations of minute oil-globules in a cell form.' " 

^^It will be seen by this extract that Beale distinguishes these 
^ small, delicate, transparent, and faintly granular cells' from the 
compound granule-cells or corpuscles of Gluge. The description 
which he gives of the first cell, with the exception of the cell being 
faintly granular, corresponds very closely with that of the ovarian 
cell, but it is incomplete, and no test is given to distinguish this from 
other granular cells/'* 




I do not think he mentions with as much distinctness and empha- 
sis as it deserves the abundant, free, granular matter floating about 
in connection with the cells. In my observations this granular ma- 
terial, having the precise appearance of the granules in the cells, was 
the most striking of the microscopic appearances. 

The chemical nature of this fluid is more constant. It is alkaline 
in reaction and highly albuminous, always coagulating when boiled 
or submitted to the action of strong acids. 

After having passed in review, as above, the items of general diag- 
nosis of ovarian tumors, I propose to enter upon a differential view 

* Thomas M. Drysdale, M.D., Philadelphia, in the Transactions of the Amei'ican 
Medical Association, 1873. 



DIAGNOSIS. 695 

of the subject, for there are conditions of disease and health of the 
contents of the female pelvis and abdomen which they may be mis- 
taken for. The following long list of conditions may be given as 
likely to be mistaken for ovarian tumor : " 1st. Retroversion and 
retroflexion. 2d. Tumors of the uterus, — solid, fibrous, or fibro- 
cystic. 3d. Pregnancy. 4th. Pregnancy complicating ovarian 
dropsy. 5th. Cystic tumors of the abdomen. 6th. Distended blad- 
der. 7th. Accumulation of gas in the intestines. 8th, Accumula- 
tion of faeces in the intestines. 9th. Enlargement of the liver, spleen, 
or kidneys, or tumors connected with the viscera. 10th. Recto- 
vaginal hernia and displacement of the ovary. 11th. Pelvic abscess. 
12th. Retention of menstrual fluid from imperforate hymen or closure 
of the OS uteri. 13th. Hydrometra. 14th. Accumulation of fat in 
the abdominal walls. 15th. Accretions in the subperitoneal connec- 
tive tissue, or in the peritoneal cavity. 

In cases of retroversion or retroflexion, if minute examination with 
the finger per vaginam and rectum fail, and the symptoms are of a 
character to make a correct diagnosis important, the uterine probe 
will at once determine the distinction. In some instances we might 
be quite unable to distinguish a small ovarian tumor from an impreg- 
nated retro verted uterus. Our proper plan in such cases is to await 
the peremptory demand for the knowledge, and then take the risk of 
introducing the probe, remembering the position of the mouth of the 
womb in retroversion, that it is not only near the pubis,, but directed 
upwards as well as forwards, and that the os, in cases of misplace- 
ment by the tumor, is not directed upward, but nearly always down- 
ward, — certainly never, so far as my experience and reading goes, 
above the horizontal position. The probe will be equally available 
in examining the retroflected organ, and I think the probe should 
always be used where pregnancy is not suspected. Should we feel 
much doubt of the existence of pregnancy in connection with retro- 
version, it would be better to lift the tumor out of the pelvis ; when, 
if it were retroversion, the uterus would be restored to its natural 
position, with the os near the centre of the pelvis. In endeavoring 
to distinguish between ovarian and uterine tumors, we should bear 
in mind that the latter almost invariably change the length and size 
of the cavity of the uterus. Where the sound is used, it will pass 
further than if the uterus was not involved. The rationale of this 
increase of size of the uterus, so generally found to be present, is con- 
nected with the fact that the development of a tumor in or from the 
walls of that organ induces general hypertrophy to some extent, as 



596 OVARIAN TUMORS. 

these growths are found to be a hypertrophy of some one of the 
uterine tissues. The tissues generally involved are the fibrous or 
mucous, as in hard or soft polypi from the internal, or hard from 
the external walls, or intramural fibrous tumors. Uterine tumors 
are so intimately connected with the uterus that this organ cannot be 
moved without imparting more or less motion to the tumor, nor can 
the tumor, on the other hand, be moved without, in a similar way, 
affecting that organ. This is not the case with ovarian tumors. 
They are so loosely connected with the womb that considerable 
motion is allowable without the other partaking of it. In the sound 
we have the means of moving or fixing the uterus, and with the 
finger may watch the effect of motion upon the one or the other, as 
the case may be. When a fibro-cystic tumor is developed upon the 
uterus, containing fluid, the examination to ascertain whether there is 
an attachment with the uterus, and with a view to learn the length 
of the cavity, will give us clear notions of the matter. When we are 
satisfied that pregnancy cannot be the condition, we may explore or 
tap it as an additional means of accuracy. 

Hard or fluid tumors arising from a distant organ or part of the 
abdomen would have a different history from the ovarian tumor. If 
our patient is intelligent, her observation as to the place where first 
noticed shou Id be relied upon as valuable knowledge respecting the 
probable point of origin. 

Ascites, w^hen excessive, may sometimes be mistaken for ovarian 
tumor, but the latter is more frequently taken for the former. When 
the patient lies on her back, with the knees drawn up, so as much as 
possible to relax the muscles, and the abdomen is entirely exposed, in 
ascites the tumidity will be rotund, filling out in every direction, and 
will particularly bulge the depending portions. The flanks will both 
be full ; the abdominal protrusion commences at the edges of the 
ribs, and will be equally soft at every point ; fluctuation will be 
greatest at the most dependent parts, and resonance entirely absent; 
fluctuation will scarcely be perceptible in the highest part of the ab- 
domen, but there w^ill be resonance there. These circumstances will 
remain the same under any change of position. If the patient stand 
up the dulness is in the hypogastric and iliac regions. If she lie on 
her side, the dulness and fluctuation on the lower side ; resonance on 
the upper side. All this results from the water freely settling into 
the lowest points, let them be what they may. In ovarian tumor, 
alteration of position from erect to recumbent, or from supine to 
prone, makes no difference in the places where resonance and fluctua- 



DIAGNOSIS. 597 

tion are found. They are manifested always in the same places. 
When the patient lies on the back, the flanks are resonant, the um- 
bilical region dull. Fluctuation is not observed in the flank in any 
position ; it is apt to be greatest under any posture in the middle of 
the abdomen. When the abdomen is exposed for inspection there 
is marked irregularity in its rotundity, and I think, ordinarily, the 
flanks, one or both, are flat. One side is apt to bulge more than the 
other. Probably there is more than one rather prominent region, — 
it may be several. There is more hardness and tension; not the 
flabby swaying under slight influences, so common in ascites. An 
important class of circumstances is the pathological condition almost 
always present in ascites. It seldom occurs in persons in the enjoy- 
ment of good health in every other respect. There is organic disease 
of the kidneys, liver, spleen, heart, lungs, or subacute peritonitis. Or 
there may be some cachexia from miasma, poison, or other bad influ- 
ence of particular places of residence, occupation, habits, or time of 
life, etc. There is some notable and grave pathological accompani- 
ment of abdominal dropsy w^iich precedes the swelling ; whereas, the 
ill-health in ovarian dropsy is the effect and not the cause. We gen- 
erally find that women preserve a good condition of health in ova- 
rian disease until far advanced, and disordered functions come almost 
always as the result of great pressure upon the sufl'ering organ. A 
complication of ascites w^ith ovarian dropsy obscures our diagnosis 
very much. If the ascites is great, and the ovarian disease not so 
considerable, the tumor will be felt floating about, as it were, in the 
abundant fluid, when the patient changes position. Excluding by 
our diagnostic examination every other disease, and leaving the ques- 
tion between them alone, we are justified in exploration and tapping. 
By the former, we come in possession of a specimen fluid, which, 
when submitted to chemical and microscopical investigation, is almost 
conclusive. By the latter, we partially empty the abdominal cavity 
and relax the walls, so that we can examine its contents with great 
freedom. If the fluid is ovarian, it will be highly albuminous, and 
possess the microscopical qualities I have before mentioned. If it be 
ascitic, the properties are those of serum found exuded anywhere from 
pressure or inflammation. There will be very little, if any, albumen, 
no epithelial cells, and the corpuscles described by Drysdale. 

It will occur very seldom that the question between pregnancy and 
ovarian disease will become so urgent that it may not safely be left 
to time. I can conceive no time or circumstance under which great 
doubt as to which of these two conditions were present but in the 



598 OVARIAN TUMORS. 

early stages of either, while in the pelvic cavity; and unless great 
pressure on the organs contained in it make delay hazardous, we 
should not interfere, but content ourselves to wait until the obvious 
evidences, as quickening and motions of the child, declare the exist- 
ence of pregnancy, or until so much time has elapsed without any 
such signs as to throw great doubt upon the subject. At such times 
the tumor is high above the pelvis, and may be subjected to any 
searching examination we may choose. Auscultation then becomes 
valuable and perfectly reliable, when properly practiced, in deter- 
mining the presence of normal pregnancy. 

Frequent examinations with the stethoscope or ear, in various po- 
sitions, should be patiently and perseveringly practiced before we 
should be satisfied to risk means of a hazardous nature that will en- 
able us positively to decide the question. After having repeatedly 
thus explored the abdomen without any sign of a live foetus, we may 
use the probe to examine the whereabouts and size of the uterus. Xo 
mistake will survive the test of tliis instrument. If I were not to 
explain myself a little more upon this point, I might incur the charge 
of rashness for recommending the sound where any doubts exist. It 
would be rash to use the sound until all the differential signs of preg- 
nancy had failed, and even then, unless the urgent demand caused 
by the influence upon the health forbids us to wait longer for a deci- 
sion. It is only in extreme cases, where the symptoms and signs 
derived from the breasts, condition of the cervix, menstruation, 
nausea, pigmentary deposits, and auscultation, had all failed, and yet 
I was obliged to act at once for the safety of the patient, that I should 
consent to use the sound. Then I would use it as the more innocent 
of the demonstrative tests, and as a derniet- ressort. It is certainly 
more innocent than the exploring needle or the evacuating trocar, and 
equally demonstrative. The worst effects its careful use could have 
would be to produce abortion or premature birth, either of which 
would be more likely to remove the urgency of the symptoms than 
do harm. I have recentlv seen an instance of the obscuritv of dias:- 
nosis, from the existence of a pregnancy of eight and a half months' 
duration, decided by the probe, which caused the discharge of a 
mummified foetus of less than four months' growth, and, as a matter 
of course, almost cured the ])atient. 

Pregnancy complicated with ovarian dropsy, may be very perplex- 
ing to diagnosticate. Mistakes of diagnosis have occurred in the 
hands of Sims, Wells, the author, and others. A careful examination 
of the cervix uteri, the abdomen, breasts, etc., for the evidence of preg- 



DIAGNOSIS. 599 

nancy above mentioned, will seldom fail to make a diagnosis of this 
complication clear. There are very few collections or growths that 
can be, in such conditions, mistaken for this. 

In pelvic abscess, there will be inflammatory tenderness and heat. 
The most likely of all others, is a prolapsed bladder. Our diagnosis, 
however, will be easily effected by using the catheter, when, if it is 
the bladder, emptying causes its collapse and the entire disappear- 
ance of the tumor. But if, after the complete evacuation of the 
bladder, there is yet a tumor containing fluid, exploration should be 
resorted to. This will clear up the diagnosis, provided the explor- 
ing trocar is large enough to evacuate a part or the whole of its con- 
tents. There are other fluid tumors, arising from the broad liga- 
ments near the ovary, probably dependent upon a great increase of 
one or more of those transparent cells of serum, so generally seen by 
looking through tliis peritoneal duplicature, towards the light. These 
may be mistaken for actual ovarian cysts, and are doubtless the cases 
of ovarian disease that are permanently cured by a single tapping. 
No means of diagnosis now known would enable us to decide, with 
any certainty, between the two except chemical and microscopic 
examination of the fluid. The fluid is a limpid serum of very low 
specific gravity, sometimes not alcove that of distilled water, often 
not more than 1004, not coagulable by heat and devoid of any micro- 
scopic peculiarity. It has a remarkable semblance in most of its 
qualities to pure water. Cystic tumors of the abdomen, arising from 
other points, and hydatids of the peritoneal cavity, can be distin- 
guished wnth certaint}' in no way except by exploration and exami- 
nation of the contents. The history will, if carefully and intelli- 
gently detailed, show something, perhaps, that we may seize upon to 
aid us. The case should commence, if ovarian, in a tumor arising 
from the pelvis, gradually ascending into the abdomen. If abdominal, 
it is first noticed in that cavity, and may descend until it occupies all 
the abdomen, and then the pelvis also. If hydatid, the increase is 
mere tumidity, not a well-defined tumor, and it commences in the 
abdomen. 

The distended bladder, accumulation of gas in the intestines, or 
of faeces, ought not, in the present state of our science, to embarrass 
us any longer than the catheter or a cathartic could be brought to 
bear upon the case. As soon as the bladder is emptied it will col- 
lapse. The gas in the bowels causes tympanitis of the abdomen, 
and thus ought to be detected. The accumulation of faeces can be 
removed, when the tumor will be gone. Hysterical distension of the 



600 OVARIAN TUMORS. 

abdomen, said to simulate pregnancy, ovarian, uterine, and other 
tumors, entirely disappears under the influence of chloroform, as 
shown by Professor Simpson, on many occasions. 

Visceral enlargement, as liver, spleen, kidneys, and tumors grow- 
ing from them, are not unfrequently mistaken for these tumors. I 
have a patient now laboring under enlargement of the spleen, who 
has been told more than once, that she had ovarian disease. Unless 
the enlargement of the liver or spleen is excessive, I cannot see how 
a mistake can be possible. The history as to where the tumor was 
first observed should be carefully traced. If either of these, it has 
descended. I have not seen a liver or spleen occupying the cavity of 
the abdomen so completely, but that its well-defined edge could be 
felt for a considerable distance, and this edge is always below, while 
the upper boundary is less defined or traceable beneath the ribs. I 
have, on several occasions, seen the spleen enlarged and dislocated, 
occupying the left iliac region, and reaching up towards the hypo- 
chondriac, but there are alwitys sharp edges somewhere. This is not 
the case in ovarian dropsy; it is round, somewhat even, and elastic 
to the touch. 

The liver is also sometimes displaced to such an extent as to rest 
upon the pelvic brim; and, when enlarged, it may occupy an exten- 
sive space in the abdomen. The three important points to be made 
in the differential diagnosis between displacements and enlargement 
of the liver and spleen and ovarian tumors are: 1st, they are flat 
in front, instead of globular ; 2d, by somewhat forcible percussion 
even very decided intestinal resonance may be heard through them; 
3d, by well-directed manipulation in the horizontal position the dis- 
placed organ may be partially or completely returned to its natural 
nidus. 

Mr. Brown mentions recto-vaginal hernia and dislocation of the 
ovary into the cul-de-sac of Douglas. The diagnosis would be diffi- 
cult and unimportant unless in exceptional cases. The great im- 
portance of a correct diagnosis is based upon the urgent symptoms and 
fatal tendency of the disease. 

Retention of menstrual fluid, from imperforate hymen (or other 
obstruction to its outlet), also hydrometra, as soon as we have by 
physical examination, history, and the rational symptoms, decided 
that the patient is not pregnant, the finger and sound will clear up 
all doubts in a short time. Obstructions will be ascertained or over- 
come by them, and our misgiving dispelled. 

Acute, and sometimes even subacute, inflammation of the peri- 



DIAGNOSIS. 601 

toneura is occasionally accompanied and succeeded by hard, fibrinous 
deposits of various sizes and location in the abdomen. When in the 
iliac and hypogastric regions they may be mistaken for tumors. They 
are flat, immovable, sensitive; yield resonance in a very decided 
manner upon percussion, and date their existence from an attack, 
more or less remote, of peritoneal inflammation. 

Supposing our diagnosis complete as to its being an ovarian tumor, 
ve have yet to learn, for the more intelligent treatment, several other 
tilings; among these are: What are the contents and construction of 
it? Is it monocystic or polycystic ? Are its contents partly solid, 
or wholly fluid ? Although, probably, not always possible to decide 
th«se questions without exploratory operations, we have some means 
of dearing them up. A diligent and careful examination by percus- 
sioL and inspection will enable us to judge correctly, in most cases, 
whether the tumor is monocystic or polycystic, or otherwise. If 
monocystic, the tumor is regular in its rotundity and outline ; if poly- 
cystic, there is some irregularity of elevation, made out best by sliding 
the hind over the surface. Fluctuation, caused by percussion, is the 
same *n all directions and from all points of it in monocystic. In 
polycMtic it is very obscure, except over partial measureaients. The 
fingers placed near each other over the same cyst feel the fluctuation 
very sensibly ; but when one is removed so as to pass over the parti- 
tion between it and the next cyst, the fluctuation becomes more ob- 
scure. By examining all parts with both hands, separating and 
approxiaating each other, we make out the dimensions and situation 
of the c}st, which lies in contact with the abdominal walls. The 
fluctuatioi, or its absence, will determine whether a given part of the 
tumor is ?olid or fluid. The hard parts of an ovarian tumor are, 
almost in\ariably, at the bottom of the tumor, and may be reached 
by the fin^r per vaginam. While our fingers are in contact with 
the base of the tumor in the pelvis, if it is wholly fluid, we may feel 
fluctuation, f the top of the tumor is struck with the other hand. If 
a solid part ntervenes between our two hands, fluctuation would not 
be experiencd. 



CHAPTEE XXXIX. 

OVAEIAN TUMORS, CONTINUED. 

Treatment. 

It is not necessary to interfere, in any manner, with some cases of 
ovarian dropsy. Indeed, it is right to let all cases alone that do not 
impair the health or threaten the life of the patient. There ^re 
many instances which advance slowly, or remain stationary fo" a 
great many years, and prove but an inconvenience. We would not 
be justified in active interference in these cases; much less sh'mld 
we do anything directly for cases in which independent complica- 
tions of a fatal character exist, e.g., phthisis or cancer, albumiiuria, 
etc. When, however, the disease is making obvious progress, and 
particularly when the advance is sufficiently rapid to leave bu: little 
doubt of its proving fatal within the average time of their duration, 
we are bound to make every eifort within our power to save ')r pro- 
long, as much as possible, the life of our patient. 

The treatment of ovarian tumors may be divided into pilliative 
and curative. The one intended to relieve, as far as posahle, the 
sufferings of the patient under the disease, or to retard the rapidity 
of its progress ; the other to remove or destroy the tumor, and thus 
do away with the cause of the evil entirely. 

When doubt exists as to the propriety of instituting radical treat- 
ment, we should continue to pursue the palliative until that doubt is 
dispelled. There are three sorts of cases to which the jalliative is 
indisputably adapted. They are, first, those in which L is not de- 
sirable to use radical means in consequence of the absenct and proba- 
ble great distance of urgent symptoms, while there is a steady ad- 
vance. The second class of cases is that in which the .ymptoms are 
urgent, but in which it is not desirable to use radical neans in con- 
sequence of the slight chances of success. The third ire such as, in 
their nature and condition, would call for curative neans, but the 
patient will not consent to their employment from fear of the danger 
or pain they inflict. The first set of cases is not verj frequently met 
with compared to either of the others; yet we do otcasionally meet 
with these slowly marching cases, in which we havf an opportunity 



TREATMENT. 603 

to try the effect of medicines; and it is precisely in this kind of cases 
that we appear to derive most benefit from medicines internally ad- 
ministered. We are apt to believe that the tardy development is 
dependent upon the virtue of some favorite remedy used, and deceive 
ourselves as to its efficiency, when really all depends on the natural 
slowness of the tumor. The alteratives, as mercury, iodine, sarsapa- 
rilla, chlorine, etc., have all had their advocates. It was at one time, 
and even now is, the practice of some men of ability to give mercury 
to very slight ptyalism, with the hope of bringing about absorption. 
Iodine, administered frequently, so as to induce its specific influence 
upon the organism, has been, and is still, by some highly lauded as 
capable of curing ovarian dropsy. A chronic administration of either 
of these remedies is sure to affect unfavorably the general health ; 
and, as it is extremely doubtful whether there is any efficacy in them, 
we should not be too profuse in their use. Effusion into the perito- 
neal sac, or subacute inflammatory complications, are often very much 
benefited by a moderately protracted course of these remedies. For 
the same purpose, local depletion, counter-irritants, such as iodine 
ointment, strong enough to induce irritation of the skin, are often use- 
ful; so are diaphoretics, diuretics, and cathartics. In the second 
class of cases we need not feel so restricted in our efforts at palliation. 
It is best, howev^er, to bear in mind that too great activity of medi- 
cation will often do more harm than good. Our object should be to 
promote such functions as are obstructed or restricted; the kidneys, 
for instance, need especial attention, as also the intestinal canal. The 
acids have always seemed to me to be particularly applicable to these 
cases. The nitric, nitro-muriatic, sulphuric, phosphoric, acetic, are 
all useful, and may be alternated often with the hope of relieving 
the distressing indigestion attendant upon great distension and im- 
perfect performance of the renal functions. They also very much 
moderate the distressing exudations from the skin, which are often 
present. The chlorinated tincture of iron is also an excellent tonic. 
These remedies may very properly be administered in some of the 
bitter infusions, — quassia, chamomile, wild-cherry bark, etc. The 
best time to give them is immediately after eating. Stimulants ought 
not to be too freely used, as they encourage the establishment of com- 
plications. Brandy I think the best of the stimulants, and it should 
be given more for the purpose of inducing sleep than anything else; 
and this it will often do when taken in a sufficient dose on an empty 
stomach at bedtime. When great restlessness and want of sleep are 
wearing out the patient, we must, as in all similar circumstances in 



604 OVARIAN TUMORS. 

other diseases, resort to the assortment of anodynes, beginning with 
the less disturbing, beino^ sure to be under the necessity of endino^ 
with opium. Chloroform, internally administered, is, I am confident, 
not sufficiently relied upon. Teaspoonful doses, given in milk, will 
seldom f\iil to induce a fine anodyne effect. There is greater neces- 
sity, perhaps, for a gradual increase of the dose in using it than 
opium, or most other efficient anodynes. Hyoscyamus, belladonna, 
cicuta, should all be tried before opium. 

We must be on the alert for complications, and ready for their 
appropriate treatment. The distressing constipation, which often 
annoys the patient and physician, will demand a great share of our 
attention. Injections of water and various substances will, of course, 
suggest themselves. It has occurred to me to be able to induce free 
movements of the bowels by having a pint of warm lard thrown high 
up in the bowels when they are very obstinate ; the longer the lard 
is retained the better. This, administered once a day, will act ex- 
cellently well sometimes. An ounce of fresh beefs-gall, with three 
or four ounces of water, often does as well. But the time comes, 
sooner or later, with the steadily increasing pressure of the tumor, 
when to lessen its size is indispensable to the further extension of 
life. 

Tapping suggests itself as the only surgical palliative in this state 
of things. This operation is more beneficial in unilocular tumors 
than in any other sort, but is applicable as a palliative measure, in 
any tumor containing fluid, when demanded by the supervention of 
urgent symptoms indicating the necessity of immediate relief. Under 
the desperate circumstances mentioned, there can be no question about 
the propriety of tapping the patient; yet this apparently trifling opera- 
tion is not devoid of inconveniences and dangers that should be 
weighed deliberately, and, if they do not deter us from resorting to 
it, will at least make us particular not to use it as anything but an 
indispensable remedy. One serious inconvenience connected with 
tapping is the readiness with which the fluid accumulates in the sac. 

The dangers of tapping are both immediate and remote. The 
immediate are such as are connected with, and occur immediately 
upon, the performance of the operation. Dr. Simpson sums up fiv^e 
that are more frequent, and against which we should be upon our 
guard. First, the chance of wounding the urinary bladder. This 
may be avoided by evacuating the organ, unless it is tied to the ab- 
dominal wall by adhesions, which we can ascertain by introducing 
the sound. Second, the puncture of the uterus when it is drawn up 



TREATMENT. 605 

with the tumor. By introducing the sound into its cavity we may 
learn its whereabouts, and thus be enabled to avoid it. Third, the 
front part of the tumor may be traversed by the Fallopian tube, and 
this last be wounded by the trocar. Fourth, the internal venous cir- 
culation, on account of the pressure, is obstructed sometimes, and the 
blood is directed to the veins in the walls of the abdomen or tissue, 
so that these veins may be wounded; but generally they are large 
and may be seen, and thus avoided. Fifth, the epigastric artery is 
sometimes wounded. We should carefully feel for the pulsation of 
arteries in the thin walls before the trocar is plunged into the tumor. 
As may be seen, these dangers may, for the most part, be provided 
against ; but the second class of dangers, namely, the remote, — those 
that follow the operation some time after its performance, and are 
not dependent on the manner or place of the puncture, — are not so 
easily avoided. 

The dangers and benefits of tapping cannot, and ought not, to be 
estimated by comparison with other operations. Each operation, of 
whatever kind, has its place, and is followed by its good or bad 
efPects, for the reason, among others, that it is appropriate, or inap- 
propriate. Generally, no two operations are applicable to any one 
condition of things ; and we should not allow the question of danger 
to decide between them, unless in very rare and exceptional cases. 
The statistics, as far as I have been able to collect them, may be well 
summed up, as Dr. West has done, and I shall rely upon his figures : 

" The chief, indeed, almost the only numerical data of which we are 
possessed, bearing on this subject, are derived from a table of 20 cases, 
compiled by Mr. Southara, of 45 cases collected by the late Mr. Lee, 
and of 64. the results of which are given by Professor Kiwisch. Of 
these 130 cases, 22 terminated fatally within a few hours or days after 
tapping, and 25 more in the following six months ; or, in other words, 
34.7 per cent, of the cases ended in the patient's death in the course of 
half a year after the performance of tapping. In 114 of the 130 death 
is stated to have taken place : 22 within less than ten days, 25 within 
six months, 22 within one year, 21 within two years, 11 within three 
years, 13 after a period exceeding three, and in some amounting to 
several years. 

" In 109 of these cases, we are further informed how often the patients 
had been tapped. It appears that 46 died after the first tapping, 10 
after the second, 25 after from three to six tappings, 15 after seven to 
twelve, 13 after more than twelve." 

It would appear that the first tapping is very much more danger- 
ous than subsequent ones. Dr. West says further : 



606 OVARIAN TUMORS. 

" Unfavorable, however, as are the couchjsions to which we are irre- 
sistibly led by such facts as those which have just been mentioned with 
reference to the ultimate issue of tapping, it is yet very questionable 
whether they represent the whole of the truth concerning this matter." 

Dr. Atlee, of Philadelphia, thinks tapping not a very dangerous 
operation. Mr. Brown thinks its dangers greatly overrated. 

There can be but little doubt that much of the mortality of tapping 
is due to the fact of the desperate character of the cases in which it is 
used ; and the reason why so many die in so short a time after the 
first operation is, that in many instances the patient is almost mori- 
bund before it is resorted to. When not attended with the imme- 
diate dangers above enumerated, tapping is either followed hy great 
relief from suffering or by the remote or sequential dangers. They 
are, for the most part, prostration or inflammation. The prostration 
is sometimes so great, that no management can prevent the patient 
from dying in a very short time. Such great prostration is, how- 
ever, exceedingly rare ; it is more common to have it in a more mod- 
erate degree. The patient w^ill feel faint for an hour or two, and 
then gradually rally, or she may continue to be pale and languid for 
several days. For such slight cases, the horizontal position, rest, and 
good, digestible, somewhat stimulating food, is all that will be 
needed. When the prostration is great, and danger of fatal sinking 
present, the case must be treated energetically. The means calculated 
to bring about reaction must have reference to the causes of the pros- 
tration. The evacuation from the general vascular system is not a 
cause, because the fluid in the tumor is extravascular ; but it is a 
sudden change in the distribution of the blood. The evacuation of 
the abdominal cavity of so large a bulk of its contents, and the in- 
ability of the abdominal muscles to contract sufficiently to keep up 
the pressure to which the viscera have been habituated, are the 
causes of the irregular distribution of the blood. The want of pres- 
sure upon the abdominal viscera, allows a large accumulation of 
blood in the veins, and it is there retained. In proportion to the 
amount thus collected in the abdomen, will the blood be withdrawn 
from other parts and organs. The brain will partake of this tempo- 
rary anaemia, and consequently be incapable of discharging its func- 
tions with its wonted efficiency. This is the condition, — not a want, 
but an irregular distribution of blood. Our first object should be to, 
as nearly as possible, re-establish the previous condition of the abdo- 
men. This can be, to some extent, accomplished by pressure, with 
compresses and rollers. The compresses should be as large as the 



TREATMENT. 607 

space covered by the muscles of the abdomen, and thick enough to 
fill up much above the level of the ribs and iliac bones on the side. 
The roller should be applied from the pubis to the ensiform cartilage, 
with as much power as the patient can bear without great discomfort. 
Then the head should be persistently kept below the level of the 
body. This simple treatment, instituted early, will do more than all 
other means without it. We can very properly, however, give 
stimulants, in addition, when necessary. When this danger is passed,' 
inflammation of the sac or peritoneal cavity is next to be appre- 
hended. The sac undergoes every degree of inflammation, from the 
slow, subacute, unobserved degree, which vitiates the fluid effused 
into it, either by causing decomposition in it, or by the production of 
pus, or effusion of blood inside, or fibrin on the external surface — in 
this last case causing adhesion — or such degeneration of the walls of 
the sac as to cause an obliteration of the cavity, a cessation of its 
secreting powers, or a perforation, and consequent peritoneal commu- 
nication ; or, what is perhaps more common, an acute degree, an- 
nounced by severe pain, referred to the point most intensely affected, 
or to the whole abdominal region, thus showing the probable involve- 
ment of the peritoneum. Indeed, I think it very probable that the 
sharp pain ordinarily present in these cases, indicates peritoneal in- 
flammation, and that there is but little pain in the case of inflamma- 
tion of the fibrous and internal coats of the sac. Fever, of a some- 
what high grade, is apt to attend upon the degree of inflammation last 
mentioned, accompanied by headache, weariness, aching in the back, 
limbs, etc. But in the inflammation of the inner coats, in which pus 
or fibrinous products are effused in the fluid of the tumor, there is 
generally but slight fever, perhaps none at first ; but the vital powers 
are more or less depressed, copious perspirations at night, possibly de- 
lirium, and in bad cases, all the symptoms of pyaemia, hectic, exhaus- 
tion, and death. Now all morbid conditions resulting from tapping 
should be met promptly by the remedies appropriate to them when 
they occur under other circumstances, — antiphlogistic regimen, deple- 
tion, fomentations, cathartics, anodynes, alteratives, etc. In pyaemia, 
tonics, stimulants, good diet, and time will be our resort. 

The operation of tapping is simple, and easily performed gener- 
ally. To avoid the depression which follows the evacuation of so 
large a quantity of fluid as is contained in the abdomen sometimes, 
we should have our patient on the side, very near the edge of the 
bed, with her head and shoulders low. Two large and long hand- 
towels should be passed around her body, with the edges close 



608 OVARIAN TUMORS. 

together upon a level with the point where we wish to introduce the 
trocar, and these ends given to an assistant, who stands behind the 
patient. The assistant having in charge these hand-towels should 
be directed to draw upon them so as to keep up a state of tension as 
the fluid is beino^ evacuated. To avoid the dano^ers enumerated as 
immediate, we should assure ourselves that the bladder is empty, and 
if we mistrust that it is not in its proper place, we should introduce 
a sound, so as to assure ourselves of the whereabouts of the fundus. 
If we have not already done so, we must sound the uterus, also, and 
thus be sure of its harmless position. After these precautions, the 
best rule, perhaps, is that given by Dr. Simpson, and that is, to feel 
for the most fluctuating point, the place where the walls are thinnest, 
look for veins and feel for the pulsation of arteries. The thinnest 
part, where fluctuation is most evident, is usually the right place to 
make the puncture ; but there is not always any such point, there 
being but little difference in this respect over the whole of the front 
surface of the tumor. In such case we may be governed by the ordi- 
nary rules for the place for tapping. The linea alba, between the 
symphysis and umbilicus, is the most eligible in the greatest number 
of cases. If any objection to this arises, a point midway between the 
umbilicus and the anterior superior spine of the ilium is, as a general 
thing, safe and efPectual as any. Some surgeons recommend other 
places as free from the objections that are sometimes urged against 
these points. They say that tapping through the vagina is quite 
safe from the immediate, and not so likely to be followed by some of 
the sequential disasters. The rectum is thought to be still better by 
some. The vagina is quite a commendable place, if we are careful 
to ascertain well the position of the bladder and uterus, and avoid 
them. Our instrument (the trocar) should be large, four or five 
lines in diameter; the point should be sharp, and a little longer than 
they are usually made. The canula if not large w^ill not freely dis- 
charge the fibrinous concretions or thick treacle-like fluid, and if the 
point is not long and sharp, we inflict considerable unnecessary suf- 
fering in the introduction of the instrument. We may plunge the 
instrument in towards the central axis of the tumor, until sent home 
to the rim of the canula. If, however, our instrument is not pretty 
sharp, it will be very much better to make an opening with a very 
sharp, thin bistoury, which will cause less suffering, and answer every 
purpose as well. 

For the purpose of avoiding some of the dangers connected with 
tapping, Mr. Wells has invented a trocar that prevents the ingress 



TREATMENT. 609 

of air, and attaches a rubber tube to the canula to carry the fluid 
clear of the patient and bed, while Dr. Emmett advises the use of 
the spray during the operation, and every effort to prevent air from 
entering the Avound. 

I have never seen any serious effects follow tapping without these 
precautions. Notwithstanding this favorable experience, I would 
advise every practicable precaution recommended by these eminent 
observers to avoid the disasters which have occasionally occurred. 

Since the general introduction of the aspirator many surgeons 
think it better practice to use that instrument in the evacuation of 
the tumor. It has been pretty well proven, however, by the late 
investigation of Drs. Liisk and Proctor, that there is not so much 
difference in dangers resulting from the use of the aspirator instead 
of the trocar, as was expected from the experience of Dieulefois and 
his followers. Several instances have been recorded in which death 
occurred from the use of the aspirator. 

The third sort of cases to which palliative treatment is applicable, 
those in which our patient will not submit to radical means, must be 
managed in almost every particular as I have described the treat- 
ment for the other two kinds. Remembering the rules and rationale, 
it Avill not be difficult to adapt our means to the end in view. 

Curative Ti-eatment 

The curative treatment of ovarian disease is believed by almost 
all authorities to be practicable only by surgical means. There are 
some very respectable writers, however, who believe that there are 
cases in which we may hope for success from medicinal and mechani- 
cal treatment without the use of surgical instruments, and they think 
that there is enough virtue in such means to warrant a trial in very 
many instances. 

The immediate objects to be accomplished are, first, to arrest the 
growth of the tumor, bring it to a stand-still, and thus avoid the 
disastrous results which attend the attainment of very large size, with 
its consequent pressure, ruptures, etc. Second, when this is not prac- 
ticable, to obliterate the sac or sacs. The sac is sometimes reduced 
by contraction to a mere knot of compressed tissues, which are more 
and more atrophied and wasted, until very slight traces of their ex- 
istence are left ; or, by inflammation and contraction, the tumor is 
converted into a fibrinous mass, enveloped in a fibrinous sac, which 
remains the same throughout life with very little alteration ; or sup- 
puration may accompany inflammation, the whole tumor be softened 

39 



610 OVARIAN TUMORS. 

down into pus, and discharged by ulcerating through the vagina, 
rectum, abdominal walls, or bladder, and all traces of it disappear. 
Or again, the walls may collapse without shrinking much, and ad- 
here by adhesive inflammation, and in this way its effusive surface 
be destroyed. 

When neither of the above two immediate objects is practicable, or 
it may not be desirable or advisable to attempt them, we may, thirdly, 
remove the whole or a part of the tumor from the abdomen, and thus 
either get rid of the whole of the offending growth, or, after a part 
is removed, hope to effect, by one of the processes of obliteration 
above alluded to, the destruction of the balance. The means used 
for the arrest sometimes cause an obliteration of the sac, and do more 
than merely stop its growth, so that it will not be the best plan to 
separately treat of those means by which we attain the first object de- 
sired. I shall consequently feel at liberty to introduce and speak 
of such as sometimes arrest and sometimes cause a disappearance of 
the tumor. 

Three general ideas seem to govern individuals who rely largely 
upon the use of internal remedies for the cure of ovarian dropsy, 
viz., that the disease is inflammatory in its origin and continuance, 
and that antiphlogistic and alterative remedies, by arresting this 
morbid process, will stop its growth, and that the conservative powers 
of the system, aided by sorbefacients and secernents, will remove 
it ; that the tumor is developed in consequence of the presence of 
some one of the cachexise, — scrofula, for instance, as Dr. Bird dis- 
tinctly avers. Physicians who entertain these notions of its origin 
hope to make a cure by changing the general action of the system by 
all the means usually recommended for the correction of scrofulous 
tendencies to disease, by tonics, good diet, properly regulated exercise, 
clothing, bathing, and specific medication ; that its origin is entirely 
independent of either inflammation or scrofula, — an hypertrophy, in 
the strict sense of the term, of certain normal conditions, — a nutri- 
tional development of tissues similar to the production of nutrition 
elsewhere. Those who entertain this doctrine believe, also, in the 
atrophicating qualities of certain medicines and mechanical appli- 
ances, and hope, by the well-directed employment of them, to at 
least arrest their growth, if not cause their removal by absorption. 
A number of cases are on record that encourage the hope of doing 
something by medicines internally administered ; and while I am 
free to state that I have really hardly any faith in them as curative 
means, the recollection of the discouraging results of any kind of 



TREATMENT. 611 

treatment forbids me too strongly deciding against their use in prop- 
erly selected cases. Nor do I think it fair to say, as has been said, 
that cases treated by internal medication and recovering are but in- 
stances of spontaneous cures, and would have done as well or better 
without the treatment. Dr. Den man, in his Midwifery , by Dr. 
Francis, at page 151, says: 

" In the beginning of this dropsy, when the increasing ovarium is first 
perceptible through the integuments of the abdomen, and sometimes in 
its progress, there is often so much pain as to require repeated local 
bleeding by scarification or leeches, blisters, fomentations, laxative medi- 
cines, and opiates to appease it. I have also endeavored to prevent or 
remove the first enlargement by a course of medicines, the principal of 
which was the ungueutum hydrargyri rubbed upon the part, or calomel 
given for a considerable time in small quantities with an infusion of 
burnt sponge, or the ferrum tartarisatum or ammoniacal, trying occa- 
sionally what advantage was to be obtained from blisters, from a plaster 
of gum ammoniacum, dissolved in the acetum scillse, or, lastly, from 
electricity. From all, or some of these means, I have frequently had 
occasion to believe some present advantage was obtained or mischief 
prevented ; but when the disease has made a certain progress, though a 
variety of medicines and of local applications have been tried, no 
method of treatment has been discovered suflSciently efficacious to re- 
move it or prevent its increase." 

Colombat is of the opinion that '^though we ought not to place 
much confidence in the means derived from medicine, strictly so 
called, we are of opinion that they ought always to be employed 
before recurring to those offered by surgery. Consequently sudorifics 
ought first to be prescribed ; for example, guaiac, sarsaparilla, and 
vapor-baths, resolvents, and, amongst them, mercurial frictions, suc- 
cessfully employed by Clark and M. Nauche ; hydriodate of potash, 
with the internal use of iodine in small doses ; sea-bathing, or salt- 
water baths, from which M. Laennec, of Nantes, says he has obtained 
most excellent effects ; the thermal baths of Aix, in Savoy, or those 
at Barege, and, lastly, antimonial frictions, cauteries, moxas, and 
blisters, applied upon the abdomen. Diuretics, such as squills, nitre, 
etc., which, according to Haller, were usefully employed by Willis, a 
decoction of ashes in the proportion of a handful to the quart of 
water employed by Petit Radel, and from which he obtained a cure 
after having punctured the cyst. Lastly, purgatives in divided doses, 
as, for instance, aloes, rhubarb, croton oil, calomel, combined with 
castile soap and sulphate of potash, etc., are other means w^hich, in 



612 OVARIAN TUMORS. 

conjunction with abstinence and compression of the abdomen, may- 
be prescribed at the commencement of the disease for the purpose of 
assisting the absorption of the fluids, at first small in quantity/' 
After trying all these, however, surgical treatment, he thinks, will 
be our only resort in a vast majority of cases. The efficient applica- 
tion of pressure seems to promise more than internal remedies. Well- 
regulated, efficient, and long-continued pressure may produce obliter- 
ating inflammation of the sacs, and consequent cure; or, by aflbrding 
great resistance to the expansion of the tumor, arrest its growth. 

Surgical Treatment. 

Resolution and absorption of an ovarian tumor is a very doubtful 
fact, however, and notwithstanding their unaccountable disappear- 
ance, should not be counted prognostically. The second object in our 
treatment, that of obliterating the sac in situ, aflbrds more reason for 
hope in properly selected cases. The means used consist of tapping, 
with pressure, with injections of stimulants to induce inflammation 
of the sac, and with injections and pressure combined ; or, what is 
sometimes successful, the establishment of a fistulous opening in the 
sac, that either communicates externally through the abdominal walls, 
through the vagina or rectum, or simply with the peritoneal cavity. 
The above-mentioned treatment is applicable, properly, to the uniloc- 
ular or single cyst cases only, as it is impracticable to tap, inject, or 
establish a fistula, when there are many sacs ; and, what is still more 
discouraging in the multilocular variety, the sacs are not only filled 
again after tapping, as is generally the case with the monocyst, but 
there is a constant reproduction, or, perhaps, it would be more cor- 
rect to say that they are continuously developed from the ovisacs that 
are matured every month. Tapping, followed by pressure or injec- 
tion, is very apt to change the condition of the tumor in one respect, 
at least, and that is, to cause adhesions to the surrounding peritoneal 
surface. In one case of unilocular tumor, in which an external fistu- 
lous opening was made after the patient had been tapped six times, 
and had iodine injections three times, the sac, so far as we could de- 
termine, w^as universally adherent ; no portion of it could be brought 
out of the wound. 

Very fortunate instances sometimes occur in which the evacuation 
of the tumor by tapping is followed by a speedy and permanent 
obliteration of the sac. It is exceedingly doubtful, however, whether 
these were not cysts developed from the broad ligament, and not 
involving the ovarian tissues at all. Certainly they are exceptional. 



SURGICAL TREATMENT. 613 

and cannot be expected in any given case, so that we ought never to 
be satisfied with tapping when our object is the obliteration of the 
cyst. 

Pressure, in conjunction with tapping, is applicable, perhaps, to a 
larger number of cases than any of the modes of treatment yet men- 
tioned. It is very much more successful in cases of the monocystic 
than in any other variety. The application of pressure to a tapped 
sac has for its object a complete closure of the cavity of the cyst in 
such a manner as to bring its walls, as nearly as practicable, in con- 
tact throughout. This at once, if thoroughly effected, modifies the 
secerning capacity of its surface, and perhaps, from the time of its 
application, arrests more or less completely the effusion of the fluid, 
x^ow, if this cannot be done so as to operate upon all the surface of 
the walls, we can almost always bring some portion of the collapsed 
walls in contact. The continuous and prolonged contact of these sur- 
faces brings about a low, and in some cases a pretty high grade of 
inflammation, causing adhesion or a change in their structure, so that 
they are no longer of the same ovisac nature, and hence they do not 
effuse the thick albumen previously produced, and the tumor remains 
inactive or shrinks, and nearly or entirely disappears ; or suppurative 
inflammation may dissolve down and discharge the mass through 
some adventitious or natural outlet. 

The manner of applying the pressure is of the greatest importance. 
The apparatus should be permanent, and exert as much force as the 
patient can bear without too great pain, fever, derangement of the 
abdominal viscera, or other indications of too acute a degree of in- 
flammation in the cyst or damage to some organ. It should be ap- 
plied to the tumor as nearly as possible, and the forcible pressure 
should be exerted alone upon the collapsed mass, so as to crowd it 
back against the sacrum, lumbar muscles, spine, and other hard parts 
of the posterior wall of the abdomen. In order to do this properly, 
after the fluid is evacuated as completely as possible, we should ex- 
amine the abdomen minutely, so as to ascertain as clearly as possible 
the position of the collapsed cyst. This will usually be a little more 
to one side than the other, and we may generally easily define its 
shape and get a good idea of its size. We should now construct a 
compact compress, corresponding in shape and size with the shape 
and size of the evacuated sac. The compress should be embraced by 
solid wood or tin outside. The compress can be made of hair, gum- 
elastic material, or napkins. If of the latter, they should be w^ell 
stitched together, so that there can be no shifting in their position. 



614 OVARIAN TUMORS. 

After attaching the soft portion of the compress to the hard firmly, 
so that any pressure upon the latter may be exerted unvaryingly 
upon the former, it may be placed immediately over the tapped tu- 
mor, and pressure applied from a direction to press it against the 
hardest part, bearing on the posterior walls of the abdomen or pelvis. 
An attentive examination of the tumor under the pressure of the in- 
strument will inform us pretty accurately as to the eflSciency, com- 
pleteness, and direction of the pressure of the compress. The com- 
press may be managed better by a belt of soft but firm leather, to 
surround the body in such a place as to press over the centre of the 
compress. The power aud direction of the pressure may be regulated 
thoroughly and at will by subjecting it to a tourniquet screw pressure 
from the belt. Of course there must be thigh aud shoulder-straps 
to the belt, in order to keep it from slipping up or down. When we 
have adapted these simple contrivances, we should turn the screw to 
such a degree as to press strongly as the patient can bear, and with 
it thereafter regulate the pressure as we may judge best. Having 
thoroughly satisfied ourselves of the appropriate adaptation of the 
apparatus, we should wrap the whole abdomen agreeably tight, from 
pubis to sternum, with a flannel roller. We should every day re- 
move the flannel roller, and examine the compress and belt to be 
sure that they are not disarranged, and if in the least so, we should 
readapt them. We may tighten the screw or loosen it each time, or 
allow it to remain untouched, as the case may be. The greatest care 
should be taken not to produce too great pressure with this compress. 
It should be loosened when chilliness, febrile excitement, or other 
general signs of distress are added to local pain ; it may be tightened 
as soon as the symptoms decline. 

This mode of applying pressure, I think, is much more efficient and 
manageable than the plan recommended by the late Mr. I. B. Brown, 
the accomplished surgeon of female diseases and injuries, of London. 
His plan is to make a graduated compress of napkins so as to fit the 
top of the pelvis, and after applying it over the tumor, so as to press 
it down into the pelvic cavity and against its back part, place over 
the whole a broad bandage tightly fastened from pubes to sternum. 
With this appliance we cannot always be accurate in the extent, po- 
sition, and rate of the pressure, and, consequently, much more skill 
and experience are necessary in its application. Its success, hence, 
was much more frequent in Mr. Brown's hands than it has been with 
the profession generally. I am not aware that Mr. Brown teaches 
the necessity of pressure to all the collapsed tumor, but understand 



SURGICAL TREATMENT. 615 

him to make most of his pressure at the origin of the tumor, — the 
ovarian region. The tumor, when collapsed by tapping after great 
distension, seldom sinks anything more than partially into the pelvis; 
the long-exercised traction upwards generally lifts the ovary of that 
side above the pelvis, and thus we may generally somewhat accurately 
fit our means to its slope and position. An objection, Mr. Brown 
thinks, sometimes applied to pressure, is the presence and great aggra- 
vation of prolapsus uteri. This objection, it will be apparent, is very 
much more applicable to his mode of causing it than the one I recom- 
mend. Multilocular tumors may be cured in this way perhaps more 
frequently than any other except extirpation, for the pressure may 
be made to bear upon and greatly influence the development of the 
small cysts that are not evacuated by pressure. I have more than 
once evacuated several sacs through one opening in the abdominal 
walls by partially withdrawing the trocar, and directing the point 
toward a full sac after the one first pierced had been evacuated. 
This should be attempted in a multilocular tumor before we use 
pressure, and it is allowable, I think, to introduce the trocar in several 
places where there are a number of cysts that cannot be reached by 
the instrument from one point. I would n6t be understood as advis- 
ing a reckless use of the trocar in these many-cysted ovarian tumors, 
but after we have decided from the circumstances of a careful exami- 
nation of a given case that tapping and pressure is the treatment, we 
risk nothing, I think, in being thorough in our efforts to evacuate as 
nearly as possible all the sacs. The bad effects arising from tapping 
and pressure are inflammation and its consequences. When there are 
symptoms of severe acute inflammation, the pressure should be re- 
moved, and leeches, cathartics, etc., should be employed to moderate 
or remove it. If the inflammation is in the sac, we should wait until 
all the acute symptoms subside before the pad or compress is placed 
again. If, however, we can satisfy ourselves that the inflammation 
is in some other part distressed by the pressure, by varying the direc- 
tion of the pressure, provided we can include the tumor under it, we 
need not wait until all the acute symptoms have vanished. I have 
a better opinion of this kind of treatment, when carefully managed 
and watched, than any other, except the complete extirpation of the 
ovary. 

Injection of the Sac. 

Another plan of obliterating the sac of ovarian tumors is to first 
evacuate, and then inject it with some substance calculated to induce 
inflammation in it, which, by its adhesive or destructive processes, 



616 OVARIAN TUMORS. 

may completely effect this object. A large number of cases are 
reported cured by this plan of treatment. For obvious reasons 
it is almost exclusively confined in its usefulness to the unilocular 
variety. Under certain circumstances only can we expect to reach 
more than one cyst at a time with the trocar and injections. When a 
cyst is simple, the patient in good health, and we succeed in properly 
managing the operation, there is not a great deal of danger in it, and we 
may reasonably hope for benefit from it. The most simple, and I think 
effective mode of operating, is to first draw off nearly all the fluid, 
except, say, one or two pounds, as well as we can judge of it, with a 
large trocar. After this is accomplished, we should pass an elastic 
catheter or other flexible tube through the canula of the trocar to the 
bottom of the cavity. With a hard rubber vSyringe we may inject the 
medicine, whatever that may be, through the catheter into the inte- 
rior of the cyst. By using this elastic tube there is no danger of fail- 
ing to carry the material to the part we desire to reach without its 
coming in contact with anything else, or being decomposed be- 
fore it arrives at its destination. The formulae for this kind of 
injections are numerous, and several different substances used. 
Iodine seems now to be the substance generally employed. Dr. 
Simpson recommends several ounces of the tincture. Six ounces 
is probably enough to use at one time. I have used on several occa- 
sions six ounces of a mixture containing one scruple of iodine, two 
scruples of iod. potass, to the ounce of water. This is certainly 
iodine enough, if specific in its influence, to cure any tumor. My 
plan is to allow it to remain in the sac instead of removing any of it. 
lodism is likely to occur to a slight extent, but to be the source of 
no considerable inconvenience. If it should be thought best to re- 
move a part, or the whole of the iodine, the better way to do it is to 
pump it out through the tube, by means of which it was introduced, 
instead of squeezing it back through the canula of the trocar. This 
plan of extracting it, precludes the possibility of allowing any con- 
tact with the peritoneum ; which in the event of disarrangement of 
the canula, might otherwise take place. Although, ordinarily, no 
great amount of acute inflammation takes place as the effect of this 
injection, yet we should remember that it sometimes does proceed 
to a dangerous extent, and be upon our guard with the means neces- 
sary to prevent a fatal degree. In fact, it would be negligence on 
our part not to watch with solicitude all the most trifling operations 
upon an ovarian cyst. It may be asked whether iodine is the best 
substance to use as an injection in such cases ? Although I have to 



SURGICAL TREATMENT. 617 

some extent fallen in with the fashion of using iodine, I cannot re- 
sist the conviction that there are substances that would do as well, 
against which some objections that apply to iodine could not be 
urged. Iodine operates promptly upon the organism when intro- 
duced in this way, by being absorbed and taken into the circulation ; 
yet, I think there can be but few; who desire anything more than its 
local effect upon the inner surface of the sac. Alcohol, wine, brandy, 
in fact any local stimulant whose general effect after absorption is 
more transient, as well as less powerful, would perhaps ans\yer just 
as well. It cannot be that the internal effect of iodine upon the kid- 
neys and other organs of excretion can enter largely into its good 
effects, for if such were the case it would be better given by the 
stomach. Injection of iodine was regarded several years ago as the 
most eligible mode of treating this affection, because of its compara- 
tive safety and frequent success ; but there can be no doubt that it 
was overrated, and now the profession is less ready to trust it. I 
believe it to be both more dangerous and less efficient than pressure 
after tapping. This is not in accordance with the opinion of Dr. 
Simpson, I believe. I have lately known of a case in which death 
occurred after having been treated with iodine injections combined, 
with pressure. I speak of this case to warn against similar proceed- 
ing, for it is plain, upon a little reflection, that if the pressure is 
properly applied, it will so lessen the cavity of the cyst as to endanger 
the effusion of the iodine, through the puncture in the sac, into the 
peritoneal cavity, and thus induce a fatal peritonitis. And if pressure 
is to be used, we should wait for two or three days after the injection. 
The last, and doubtless most effectual plan, for obliterating the 
sac, is the establishment of a fistulous opening, communicating with 
the peritoneal cavity, or the external surface, directly or indirectly, 
through the vagina or rectum. This plan is also the most dangerous 
plan, resulting in a large number fatally. Quite a difference in the 
effects, both remedial and morbid, may be remarked in the different 
places for the fistulous opening. When properly and carefully 
managed, the opening in the peritoneal cavity is productive of least 
harm, and less likely to be followed by a cure. The opening in the 
vagina is more effective, and the direct opening through the abdomi- 
nal walls both more efficacious and more hazardous than any of the 
others. When a communication is perfected and perpetuated between 
the cavities of the tumor and the peritoneum, the surface of the latter 
being a better absorbing surface, the contents are absorbed, thrown 
into the circulation, and eliminated by excretion through the kidneys 



618 OVARIAN TUMORS. 

and alimentary canal. This process being carried on more rapidly 
than the secretion by the tumor, the latter is allowed to contract more 
and more, until its secreting surface is wholly lost, and indurated tis- 
sue is all that is left behind to mark its former existence. Some very 
important precautions are necessary to such happy results, as will 
appear by an attentive consideration of the subject. It is found, for 
instance, that sometimes the contents of the tumor are poison to the 
peritoneal lining of the abdomen, and therefore fatal inflammation 
may result from its effusion into the cavity. We cannot say, without 
an inspection of the fluid, whether this is likely to occur upon per- 
formance of an operation or not, and I fear that we can by that means 
arrive at only a presumption upon the subject. In evacuating for the 
first time these growths we find, occasionally, clear, transparent, good, 
innocent-looking fluid begin to flow, when, as the flow continues, the 
latter part looks darker, grumous, and ill-conditioned ; now, whether 
we might not be deceived upon inspection is a matter of question, and 
really furnish a virus to the surface of the peritoneum, instead of the 
bland albumen of the healthy ovarian tumors. However this may 
be, we do know, from cases placed on record by Dr. Simpson partic- 
uarly, and observed, not un frequently, that these tumors do some- 
times burst into the abdominal cavity, and disappear, without any 
bad symptoms, so that we are justifiable in hoping the artificial open- 
ing may result well. Dr. Simpson recommends (and it is certainly 
the most sure way, although, as I have remarked, we must, under all 
circumstances, be in doubt), prior to opening communication with the 
peritoneal cavity, that we tap the tumor, and remove some of the fluid 
for examination, and if it is the ordinary bland, mucilaginous, trans- 
parent substance found generally after first tapping, he assures us we 
may proceed to the operation unhesitatingly ; or rather, may keep 
the puncture in the sac open afterwards, instead of allowing it to close 
up, as it usually does. This is done by, in the first place, not re- 
moving nearly all the fluid from the sac by tapping, but allowing 
enough to remain to keep it partially distended ; and, in the second 
place, every twenty-four hours so to press upon the tumor as to well 
up the fluid through the opening in the sac, and thus break the slight 
adhesions which may have formed between the edges of the wound, 
and allow it to escape into the peritoneum. Dr. Simpson thinks this 
is the safer way, so far as the" danger from the operation is concerned, 
but, as will be seen, not so certain of accomplishing the object. He 
has cured cases in this way. The most effectual and the most danger- 
ous way is to cut down upon the tumor, and remove a piece from its 



SURGICAL TREATMENT. 619 

wall large enough to insure patency, withdraw a part of the fluid, 
and then close the wound in the abdomen, and allow the rest of the 
fluid to flow into the peritoneal cavity thence to be absorbed. The 
immediate danger in this operation is that of dividing some of the 
bloodvessels which ramify through the walls of the tumor, and thus 
allow internal haemorrhage to take place. To avoid this it is recom- 
mended by Mr. Brown to draw out, examine, and divide only that 
portion which is clear of vascular ramifications. Others have recom- 
mended to tie any branch large enough to bleed. There is but little 
doubt that the precaution recommended by Mr. Brown would be suf- 
ficient to avoid that difiiculty. The large wound through the peri- 
toneum makes the chance of inflammation in that membrane greater 
than the mere puncture of the trocar. Upon the whole, I think I 
should prefer Dr. Simpson's plan of keeping the opening made by the 
trocar in the tumor patent, by frequent well-directed manipulation. 
It ought to be practiced, I think, oftener than every twenty-four 
hours ; as often as every twelve, for the first two days. It will, prob- 
ably, be found, upon extensive trial, that it may not always be prac- 
ticable. Should there be adhesion at the point where the trocar passes, 
it would necessarily fail. 

The plan for making a fistulous opening externally is more prac- 
ticable, perhaps, than the one just detailed, from the consideration 
that it is more manageable. 

The operation is simple, and not attended with much immediate 
danger, the danger coming in the shape of acute inflammation soon 
after the operation, or exhausting suppurative inflammation and its 
attendants. ]Mr. Brown, who has given it a more extensive trial 
than anybody else, selects a point midway between the umbilicus and 
the anterior superior spines of the ilium of the side in which the 
tumor originated. His plan is to make an angular incision at this 
point down to the peritoneum, dissect up the angle from that mem- 
brane so as to completely expose it, evacuate the tumor through this 
exposed part with a trocar, stitch the sac to the sides of the opening, 
enlarge the puncture in the cyst, and keep it open by a pledget of 
lint or other substance, as he finds most convenient. Others cut down 
to the peritoneum, at a point midway between the umbilicus and 
symphysis pubis, stitch the sac to the sides of the wound, and keep 
open by lint or stomach-tube. Care should be taken, especially if 
the contents of the sac should have a suspicious appearance, to pre- 
vent it escaping into the peritoneal cavity. Often there is adhesion 
at this part, when the stitches will not be necessary. This opening 



620 OVARIAN TUMORS. 

should be kept patent until the cavity of the cyst is lost by contrac- 
tion, inflammatory adhesion, or granulation, or all these combined, 
which is probably the common mode of their disappearance. Some 
difficulty will be found in doing this, there is such a strong tendency 
in the wound to contract and heal up by granulation. If necessary, 
we may from time to time somewhat enlarge it with the knife, and 
we should not allow it to close until the discharge has entirely ceased. 
From what I can see of the dangers of this operation, they are very 
little, if any, less than those of ovariotomy, and I should not feel 
induced to resort to it unless it were in a simple cyst, where tapping, 
injection of iodine, or the use of pressure had entirely failed, or where, 
after exposing the cyst, ovariotomy was found impracticable from ex- 
tensive adhesions. This I have done in one instance. The adhesions 
were so extensive that the cyst could not be removed; in fact, they 
seemed to be about universal; the incision was small, only admitting 
two fingers; the sac had adhered at the point where the opening was 
made, so the incision was all that was necessary in the way of an 
operation. The patient died of acute peritoneal inflammation in three 
days afterwards. A post-mortem examination revealed extensive 
inflammation of the sac and peritoneum. 

Professors Kiwisch and Scanzoni, of Wurtzburg, are warm advo- 
cates of a fistulous opening through the vagina into the tumor, to be 
kept open until the same obliteration takes place that was spoken of 
as occurring in the case of opening through the front walls of the 
abdomen. Scanzoni operated on fourteen cases: eight resulted in a 
perfect cure; in two, the fluid collected again in a few weeks; one 
died of typhus fever two months after; and three were lost sight of. 
In none of the fourteen did death occur as a consequence of the pro- 
ceeding. He mentions one case only, in his whole experience, in 
which death occurred from peritonitis, and that was Professor Ki- 
wisch's case. Scanzoni admits its danger, but shows quite a favor- 
able opinion of it. Dr. West gives three cases of his own, two of 
which were cured, but had formidable inflammation; the third died, 
not as an eflect of the operation, but from something else, which he 
does not state. Scanzoni taps with a trocar through the vagina, and 
allows the canula to remain until the cure is effected.* This, of 
course, occupies a variable time. The tube is withdrawn by Scanzoni 
by the eighth or tenth day in some cases. He says that some of his 



* The only case I have operated on in this way died of pyaemia from suppuration 
of the cyst. The canula remained for fifteen days. 



SURGICAL TREATMENT. 621 

cases recovered without any sign of inflammation or other inconveni- 
ence. Dr. West operates by introducing the trocar and withdrawing 
the fluid, passing a number twelve catheter through, and removing 
the canula over the catheter. The catheter is allowed to remain until 
the cure is complete. The cyst cannot always be reached from the 
vagina, and only in such cases#as it is crowded down into the pelvis, 
so as to give obvious fluctuation in that canal, should we think of 
this operation. 

When the cyst is discovered while yet small and occupying the 
posterior cul-de-sac, tapping and drainage will often result in a cure. 
I have once succeeded in obliterating a tumor as large as an orange 
by this method. Dr. Emil Noeggerath, of New York, thinks their 
growth may be arrested with much certainty by puncturing them 
with a very fine trocar or hypodermic syringe. He says he has 
treated about ten cases by this method, and is so well satisfied with 
the results as always to attempt the cure of small cysts in this way. 
He has also improved upon the operation of Kiwisch and Scanzoni 
by making a free incision into them through the vagina, and stitch- 
ing the sac to the incision. He has thus succeeded in draining 
quite a number of large ovarian cysts. Another method of treating 
these small cysts, original with Dr. Noegerath, consists in rupturing 
them by pressure between the fingers of one hand in the vagina and 
those of the other above the symphysis pubis.* 

Electrolysis. 

Among the expedients for the treatment of ovarian tumors must 
be enumerated electrolysis, for although it has not been subjected to 
the test of experience, yet there have been a number of undoubted 
cases of cure by this process. 

Dr. Paul F. Munde, in an exhaustive paper, published in the second 
volume of American Gyncecological Transactions, sums up the result 
of his research thus : " Out of fifty-one cases twenty- eight were either 
completely cured or permanently relieved. This makes about fifty- 
five per cent. Thirteen, or 25.4 per cent., were followed by danger- 
ous and even fatal results, nine of which, or 17.6 per cent., proved 
fatal. Six cases were not affected by the treatment, and four were 
temporarily improved. Thus in twenty-three cases, or 45 per cent., 
the objects of treatment were nc^t attained." 

It is not fair, however, to compare the results of obphoro-electro- 

* Second volume Transactions of the American Gynaecological Society. 



622 OVARIAN TUMORS. 

lysis with ovariotomy as practiced by expert ovariotomists^ because 
electrolysis is in its infancy, while ovariotomy has undergone vast 
improvements since it was first introduced. If we recall the time 
when ovariotomy was regarded as an unjustifiable operation on ac- 
count of its want of success, and remember, that the fatality of that 
operation depended greatly upon tl>e imperfection of its execution, 
and greater lack of skill in the after-treatment, we are warranted in 
indulging the hope that electrolysis may some day emerge from its 
present uncertainty and claim success to sufficient degree to be ap- 
plicable to certain conditions of ovarian cases. 

There are two methods of applying electrolysis to ovarian tumors, 
one is the external or precutaneous, in which the electrodes are ap- 
plied over the skin in such a manner as to allow the current to pass 
through the tumor. This method is less prompt and also less dan- 
gerous in its effects. 

Dr. Frencisco Dichiara, Professor of Surgery, Palermo, Italy, re- 
ports a case in which there was great constitutional debility caused 
by some three hundred sittings. (Dr. Munde's paper.) 

The other plan of electrolyzing the tumor consists in inserting one 
or more needles into the tumor and connecting it or them with one 
electrode, while the other electrode is applied over the surface of the 
tumor or in the vagina, or by applying both electrodes to needles in- 
troduced into different parts of the tumor. 

Experimenters in this practice are not sufficiently definite as to the 
kind of battery, the strength of current, the frequency or length of 
time of each sitting. These conditions, as well as the character of 
tumors likely to yield to the treatment, are points to be ascertained 
by further experiment. Neither is it yet determined whether the 
constant current or the induced is the better to use. 

Dr. Trommhold, of Buda Pesth, is reported by Semeleder to have 
cured an ovarian cyst by the external application of the Faradian 
current. 

For further information on this interesting subject, I would refer 
the reader to Dr. Munde's paper, and to one in the New York Medi- 
cal Journal, of June, 1876, by Dr. Frederic Semeleder. 

The third object in the treatment, partial or complete removal of 
the growth, remains to be considered. 

Vaginal Ovariotomy. 

Six cases of vaginal ovariotomy are now on record, by Drs. Thomas, 
J. F. Gilmore, of Mobile, C. E. Wing, of Boston, W. Goodell, of 



\ 



SURGICAL TREATMENT. 623 

Philadelphia, R. Davis, of Wilkesbarre, Pa., and Robert Battey, of 
Georgia, all of which were successful.''' 

The practice originated with Dr. Thomas. The operation consists 
in raaking an incision through the posterior wall of the vagina, punc- 
turing the cyst, withdrawing it, and tying the pedicle. 

Dr. Thomas ligated and returned the pedicle, and closed up the 
wound. The most disagreeable circumstance following his operation 
was a smart attack of pelvic cellulitis. In Dr. Goodell's case the 
cyst was in a state of suppurative inflammation, and had contracted 
many adhesions, which he overcame by introducing the fingers through 
the incision and traction with the volsellum forceps. 

The expediency of this operation is unquestionable where the diag- 
nosis is complete, because the favorable termination of the cases indi- 
cate a greater degree of safety than abdominal ovariotomy, and the 
patient escapes the annoyance and dangers which attend the great 
development that necessarily follows, especially when the operator is 
an experienced gynaecological surgeon. 

I should decidedly favor the idea of leaving the vaginal incision 
open for drainage, and through which the cavity might be washed 
out, to prevent septic poison from entering the system. 

* Eiumett's Principles and Practice of Gjneecology. 



CHAPTER XL. 

OVAEIAN TUMOES, CONTINUED. 
GENEEAL OBSERVATIONS. 

Abdominal Ovariotomy. 

During the time that surgeons were experimenting with different 
methods of performing ovariotomy, the incision was made in different 
localities, but now all operators make it in the linea alba, and between 
the umbilicus and the pubis. 

As to the length of the incision, the exigencies of the case must 
govern us. Three inches will often be sufficiently long to permit 
the removal of an oligocystic tumor with slight or no adhesions; 
much more frequently, however, it will be necessary to make the in- 
cision five inches long; very seldom will it be necessary to make it 
longer than this. 

Mr. Wells thinks that incisions which do not extend above the 
umbilicus are safer than those which do. Dr. Peaslee believes that 
the incision may be too short; less than three inches he thinks more 
dangerous than a greater length. The practical rule, according to 
Peaslee* (and I fully concur with it), is to make the opening into 
the peritoneal cavity for the removal of the tumor at least three 
inches long at first, then to prolong it if necessary, and only so far 
as is actually required. 

If the incision is to be carried above the umbilicus, it should be 
carried around to the left and then back to the linea alba. 

Treatment of the Pedicle. 

Operators have not arrived at the same unanimity in reference to 
the management of the pedicle that obtain as to the size and location 
of the incision. 

The application of the clamp is a very simple way of securing the 
vessels in the pedicle. After the tumor has been withdrawn from 
the abdominal cavity, the pedicle should be embraced by the clamp 
within half an inch of it. 

* Ovarian Tumors, p. 417. 



TREATMENT OF THE PEDICLE. 625 

The instrument should be tightened with sufficient force to per- 
fectly secure the vessels against bleeding. The pressure should be 
as great as possible to not cut through the intervening tissues. After 
preparing the peritoneal cavity, the wound may be closed by silk 
sutures from above downward, the clamp placed crosswise on the 
skin at the lower extremity of the incision. Mr. Wells directs us 
to tan the extremity of the pedicle extending beyond the clamp with 
persulphate of iron. 

In from four to ten days, sometimes longer, the instrument will 
become detached and may be removed. 

Mr. I. Baker Brown, according t<) Peaslee, first nsed the actual 
cautery to divide the pedicle. A clamp is first applied so as to secure 
and fix the pedicle, and then the cautery at a red heat is applied in 
such a manner as to cook the parts between the tumor and the 
clamp, and afterward to burn through the pedicle and thus sepa- 
rate it. 

If we have the iron at so low a temperature that we can make a 
prolonged contact and pass it over a larger space, the coagulation of 
the albumen in the tissue is so complete that there is no danger of 
haemorrhage. 

If, however, the cautery is very hot, it will sever the arteries with- 
out consolidating the parts, and thus permit as free bleeding as if the 
division was made by the knife or scissors. 

The thermo-cautery of Paquelin, or the galvano-cautery, are the 
handiest instruments with which to cauterize the pedicle, but iron 
cauteries heated by properly constructed blowpipes, or a small porta- 
ble furnace, such as is used by tinners for soldering purposes, will 
answer very well. 

Dr. G. H. B. McLeod, of Glasgow, first conceived and executed 
the idea of securing the vessels by torsion of the whole pedicle. He 
twisted it with two stout forceps. Torsion of the vessels separately 
has also been practiced successfully. 

The ecraseur has been used for dividing the pedicle. In my first 
case of ovariotomy I divided the pedicle with that instrument, and 
secured it in the wound with its edge upon a level with the skin by 
passing the pins through it with which I closed the wounds. 

Many other methods of securing the vessels in the pedicle have 
been devised, a thorough summary of which may be found in the 
admirable work of Dr. Peaslee, above mentioned, to which I would 
refer all who wish to study the subject in an extensive manner. 

40 



626 OVARIAN TUMORS. 

The Ligature. 

It remains for me In this connection to say something in reference 
to the ligature which I generally use as a means of securing the ves- 
sels of the pedicle. 

The kind of material used for ligating the pedicle has engaged 
the attention of the profession for a long time. Silk, hemp, catgut, 
horsehair, fibres from tendons of animals, — notably the deer, — metallic 
wire, etc., have all been used successfully, and most of them earnestly 
recommended by those who have tried them. 

Four qualities seem to be of material importance, if not essential to 
uniform success, viz. : 1st. SuflScient pliability to secure perfect 
adaptation to the inequalities of the structure and density of the 
pedicle. 2d. Strength to bear the force necessary to complete the 
constriction of the vessels. 3d. Solidity enough to resist the effects 
of moisture for a sufficient time. 4th. Absorbability. Of all the 
articles mentioned in the list I think silk is the only one that pre- 
sents all these qualities to any desirable extent, and I think it is now 
generally regarded as the best material for ligation of the pedicle. 

The ligature should be long enough to enable the surgeon to 
manipulate it easily and handle it securely. If the pedicle is of suf- 
ficient length to permit of it, we should not apply it nearer than an 
inch to the tumor, and then separation should be made close to the 
tumor, thus giving almost an inch of tissue beyond the ligature. If 
the pedicle is too short for this we ought to cut into the tumor to 
lengthen out the substance beyond the ligature. This will do away 
with the danger of retraction and consequent loosening of the liga- 
ture. I have known of one fatal case of haemorrhage resulting from 
retraction of the tissue of the pedicle through the ligature that I 
have no doubt might have terminated otherwise if this precaution 
had been observed. 

Should the ligature be cut short, or left out of the lower angle of 
the wound ? Dr. McDowell, in his first operation, tied the pedicle 
with a strong ligature, and left the end hanging out of the wound, 
and, before we learned how to use antiseptics, I have no doubt that 
was the best way to use the ligature, as it kept the wound open and 
acted as a means of drainage. But such use of the ligature is incom- 
patible with antiseptic treatment, for the reason that it permits the 
ingress of septic particles. There can be no question that, as the 
operation is now done under the carbolic spray, we ought always to 
cut the ligature short, return the pedicle carefully to its proper place, 
and close the wound as completely as possible. 



DRAINAGE. 627 

Drainage. 

It will be noticed that, in the description of the operation, I have 
not alluded to the subject of drainage. I believe, nevertheless, that 
there are some cases in which, some time during the after-treatment, 
drainage will become necessary. 

If the difficulties of the operation render it impossible to secure 
the patient against hsemorrhagic transudation, — a thing scarcely pos- 
sible with our improved methods, — a drainage-tube might be inserted 
at the close of the operation. 

Drainage will become necessary more frequently after septic symp- 
toms have developed. 

After operating with all the antiseptic precautions now so easily at 
our command, we should be careful not to be too ready to decide that 
drainage is advisable, for it is not certain that even if some blood and 
serum should escape into the abdomen after the operation, it is not 
rendered innoxious by antiseptic precautions. The case of Dr. Goodell 
would seem to indicate that decomposition does not always occur in 
accidental effusion. 

Should Ave conclude to employ drainage from the beginning, I 
would generally prefer to use the glass tube employed by Dr. Thomas 
and others, by introducing it through the lower angle of the wound 
to the bottom of the cul-de-sac, behind the uterus. Or, as Dr. Atlee 
told me, in conversation upon the subject, he sometimes made a 
siphon of thread or linen, by placing it in the lower angle of the 
wound, and leaving the outer end much longer than that within 
leading from the bottom of the pelvis. It should be remembered 
that the drainage-tube does not evacuate clots of blood ; and that, as 
blood coagulates almost immediately after extravasation, it is con- 
sequently not removed by this kind of drainage. 

In all cases where septic fever is developed some days after an 
operation we should examine the pelvis through the vagina, and, if 
fluid or clots are found behind the uterus, we should make a free 
opening and evacuate it. After thus removing the decomposing fluid 
we should introduce a somewhat large tube, and throw hot water, 
slightly impregnated with carbolic acid, through it, and wash out the 
cavity from which the offending material has been evacuated, and 
leave the tube in place until the symptoms have subsided. 

The value of the antiseptic method employed during the opera- 
tion and after-treatment is so well established that I do not consider 
it necessary to do more than to express my concurrence in its use, and 
nsist that no ovariotomy should be performed without it. 



CHAPTEE XLL 

ABDOMIXAL OVAEIOTOMY, CONTINUED. 

Befoee describing ovariotomy, I propose considering some of the 
more important questions presenting themselves to us, and which 
often embarrass the experienced operator. 

First. Shall we operate on a small tumor? This question may be 
answered, with some qualifications, in the negative. As our object 
is to save the life of the patient rather than to remove the tumor, we 
should wait until some condition connected with the growth of the 
tumor begins to affect the health and thereby threaten the life of the 
patient. Until the life of the patient is jeopardized by the effects of 
the tumor upon the general health, in some way, we have no moral 
nor professional right to subject her to so great a risk as is incurred 
in ovariotomy. 

Inflammation in the Tumor. 

We should regard inflammation in the tumor, whether the tumor 
be large or small, with or without suppuration, as an indication for 
immediate operation, as the risks of the inflammation are very great, 
and are probably lessened by the removal of the tumor. This is 
especially the case if the inflammation is attended with hectic symp- 
toms. 

Although rupture of the cyst and effusion into the peritoneal cavity 
is not always attended with grave symptoms, yet the supervention of 
peritonitis to a serious degree, or a toxsemic state of the system which 
threatens life or the general welfare of the patient, demands the opera- 
tion for the removal of the tumor, large or small, and drainage of 
the peritoneal cavity. 

Pregnancy neither absolutely contraindicates nor demands ovariot- 
omy. Unless there is very injurious pressure from distension, the 
operation is not demanded, and we should wait for that condition 
before we determine to interfere in any way. When dangerous pres- 
sure does occur, if the tumor is multilocular to such a degree as to 
make it impossible to remove any considerable quantity of the fluid 
by tapping, the choice lies between evacuating the uterus and remov- 
ing the tumor. Dr. Barnes is in favor of inducing abortion first, 



PREGNANCY WITH THE TUMOR. 629 

and removing the tumor after the patient recovers from this opera- 
tion, and the symptoms require it; while Mr. Wells advocates and 
practices the removal of the tumor, and a number of successful cases 
attest the soundness of his judgment. If, however, the tumor is oli- 
gocystic, or presents a large sac from which a great quantity of fluid 
may be removed, and much room thus gained, the tumor may be 
tapped once or several times until gestation is completed. I have in 
this way treated two cases, in which gestation went on to term, and 
the patients gave birth to living, healthy children. From one of 
these I removed the tumor six months after the child was born; 
the other, although the child is nearly a year old, is still carrying 
her tumor with comparative comfort. 

Sometimes errors or carelessness in diagnosis lead us into mistakes 
of so grave a character as to call for unexpected resources. One of 
them is the unsuspected coexistence of pregnancy and ovarian tumor, 
and the wounding of the gravid uterus during the operation. I have 
collected the following cases as illustrative of the proper method of 
managing them. 

The rarity of this class of cases, and the interest attached to them 
in a diagnostic and therapeutic sense, leads me to report the following 
case of my own, and to collect all I can find of a similar character:* 

A physician from a neighboring city visited Chicago, accompanied 
by a patient, to consult me about an ovarian tumor. The physician 
is a man of the highest standing in the profession, and of unquestion- 
able integrity and honor. 

The tumor had been first noticed about one year previous to my. 
seeing the patient, and had grown more rapidly in the last six months. 
The diagnosis given by the doctor was easily verified, viz., an ovarian 
tumor, most likely originating in the left ovary, and probably mono- 
cystic in character. The patient was an unmarried lady, twenty-three 
years of age, very modest in her demeanor, and, as I was assured by 
friends, of unblemished reputation. The cessation of the menses had 
occurred at an uncertain period, expressed by the term ^'several 
months since." Before visiting the city, her physician had proposed 
a vaginal examination, as one of the means of adding certainty to the 
diagnosis; but the patient begged so hard to be spared from what she 
regarded as a huuiiliation, that he was induced to yield to her wish. 
When I investigated the case, she shrank from it with much ear- 
nestness, and very plausibly contended that it could not be necessary,* 

* From American Obstetrical Journal. 



630 ABDOMINAL OVARIOTOMY. 

as neither of us seemed to have any doubt as to the presence and na- 
ture of the tumor; consequently I, too, omitted this important means 
of diagnosis. At this interview it was determined that an operation 
could not be long postponed, and that, as soon as arrangements could 
be made, I should remove it at her own home. 

Accordingly, in about two weeks, I was informed that everything 
was in readiness, and the patient desired to be relieved at once. Upon 
my arrival, I met four physicians besides the attendant, and in their 
presence another careful examination was made, and as before, and 
for the same reasons, vaginal exploration was dispensed with. All, 
however, seemed perfectly satisfied with the correctness of the diag- 
nosis, and the necessity of an operation for the removal of the tumor. 

Preparations were at once perfected, the patient etherized, placed 
upon the table, and an incision about three inches long in the linea 
alba exposed the sac. After assuring myself that there were no ad- 
hesions on the anterior surface, I introduced Spencer Wells's trocar, 
and drew off about twelve quarts of an amber-colored fluid. The fluid 
was thin, but somewhat viscid, presenting the appearance I had often 
witnessed in ovarian tumors. When the sac was nearly emptied, I 
noticed a tumor behind it, adhering to the sac and preventing it from 
passing out through the incision. The second tumor was elastic, and 
so perfectly resembled a secondary cyst that I had no hesitation in 
plunging the trocar through its walls, with a view still further to 
lessen the bulk of the entire mass by evacuating its contents. As 
the trocar met with unusual resistance, and nothing but blood passed 
through it, I became convinced that there was something unusual 
about it. The incision was somewhat enlarged, and as much of the 
emptied sac drawn out as would pass, when it was discovered that 
slight adhesions, and not continuity of tissue, connected the two. 
After the cyst was entirely withdrawn, I was astonished to find that 
the second tumor was the impregnated uterus, and, still worse, that 
it was wounded and bleeding. This revelation was accepted with 
many doubts by the physicians present, who were the friends and 
neighbors of the patient, and believed it impossible that she should 
be pregnant. The facts were so patent, however, as soon to overcome 
their incredulity. 

At that moment I did not call to mind an almost precisely similar 
instance that had occurred to Mr. Wells, and could not recall a prece- 
'dent for my guidance. The wound in the uterus had been very much 
enlarged by the contraction of the transverse, oblique, and longitudi- 
nal fibres of that organ, until, in the few moments that had elapsed 



PREGNANCY WITH THE TUMOR. 631 

since the puncture, it had become as large as a silver dollar. It 
seemed to me, in the short time I had for reflection, that the only- 
way out of the difficulty was to evacuate the uterus. This was done 
by making an incision about four inches long from near the fundus 
downwards, so as to include the accidental aperture. The incision 
exposed the placenta at about the middle of its attachment. This 
organ was easily and rapidly separated by passing the index finger 
between it and the uterine walls, and completely removed. After 
this was done, the right side of the foetus, the arm, hip, and feet were 
perfectly exposed. The breech was seized and drawn towards th.^ 
opening, when the foetus Avas expelled by uterine contraction. The 
membranes and liquor amnii were next removed, when the uterus 
was perfectly devoid of all its former contents. 

Gestation had advanced to about the middle of the seventh month. 
The foetus evinced no signs of life after its removal, and had doubt- 
less died from the effect of haemorrhage from the wounded placenta. 

The incision in the uterus was closed by interrupted sutures of fine 
silk, including the visceral peritoneum, the whole of the muscular 
wall, and the mucous membrane. The sutures were cut short, and 
no provision made for their removal. By the time the sutures were 
all inserted and tied, the uterus had contracted very firmly. 

Thanks to the valuable aid afforded me by the gentlemen present 
(whose names for obvious reasons I dare not mention) neither blood, 
nor amniotic, nor ovarian fluids had found their way into the peri- 
toneal cavity. 

In order to secure a free exit of the lochia from the cavity of the 
uterus, and thus prevent the danger of its passing through the wound, 
the OS uteri was freely dilated with the finger, and a long flexible 
catheter left in it some hours. The pedicle of the ovarian cyst was 
tied with a double ligature of plaited silk, and returned into the ab- 
dominal cavity. The ligatures were brought out at the lower angle 
of the wound, and left long enough to hang down between the 
thighs. The wound in the abdomen was closed by interrupted 
sutures, and dressed with a thick layer of carbolized cotton batting. 
The only interest connected with the future progress of the case is, 
that there was not a disagreeable symptom, except a few trivial after- 
pains. 

After the operation was concluded, I was consoled for my error in 
not making a vaginal examination, and consequent ignorance of the 
complicating pregnancy, by the assurance of all the gentlemen who 
assisted me, that their confidence in the chastity of the patient was 



632 ABDOMINAL OVARIOTOMY. 

equal to their reliance upon the faithfulness of their own wives, and 
that a suspicion of her purity would not be entertained by any one 
who was acquainted with her. Her complete recovery, however, 
and up to the present time her own entire ignorance that a foetus had 
been removed with the tumor, together with the preservation of her 
reputation, which could not have been done by any other course, 
fully compensates me for the chagrin I felt for all my shortcomings 
in the case. 

I have purposely omitted names, dates, and places, to avoid the 
possibility of identification of the patient ; I am persuaded, however, 
that this will not detract from the interest of the case. 

As the subject and manner of closing the w^ound in the operations 
for gastro-hysterotomy is now under discussion, I would call atten- 
tion to this part of the procedure. The entire absence of septic or 
inflammatory symptoms, I think, gives evidence that there was no 
escape of blood from the edges of the wound, or from the uterine 
cavity into the peritoneal sac, and warrants us in assuming that the 
closure by sutures was judicious, if not the all-important condition of 
success. After the operation, it was quite apparent that a great 
change must take place in the relation of the edges of the incision in 
the uterus, to allow the least drainage into the peritoneal cavity. 

The frequent occurrence of pregnancy during the growth of ovarian 
tumors is recognized by all experienced ovariotomists, and is a subject 
for consideration in all instances where a diagnosis is to be made 
preparatory to the removal of the tumor. Under ordinary circum- 
stances, the diagnosis of this complication is not very difficult, as the 
uterus lies anterior to or on one side of the tumor, so that its presence 
and contents are easily ascertained, but exceptional cases are some- 
times found when the difficulties are sufficient to mislead an ex- 
perienced and accomplished observer. Mr. Wells acknowledges mis- 
takes in his own practice, and mentions the fact that Dr. J. Marion 
Sims fell into an error of diagnosis and did not discover the compli- 
cation until the gravid uterus was exposed during the operation for 
the extirpation of the ovarian tumor. A considerable number of 
other cases might be cited in which mistakes of this kind have oc- 
curred. The probabilities are that more of these errors arise from 
insufficient scrutiny in cases where the diagnosis might be made, than 
from an entire iui possibility to ascertain the true state of things. 
Our improved methods of examination, and more perfect knowledge 
in interpreting the phenomena of pregnancy, ought to secure us 



PREGNANCY WITH THE TUMOR. 633 

against errors of this kind in all but the very rarest combination of 
circumstances. 

As the known cases in which the double operation of ovariotomy 
and hysterotomy has been performed are very few, I have collected 
all I could find with my limited means of research, and will not 
apologize for reproducing them in a condensed form in this con- 
nection. 

Mr. Wells publishes a case, alluded to above, in his well-known 
work on Diseases of the Ovaries^ almost exactly like the one I have 
recorded. It was first reported in the Medical Times and Gazette of 
September 30th, 1865. 

He had entirely overlooked the existence of pregnancy with ova- 
rian disease, and after removing an adherent multilocular cyst of 
the left ovary, he felt what he thought was a cyst of the right ovary, 
— tapped it, and then found it was the gravid uterus. From this 
puncture two or three pints of bloody fluid escaped through the 
canula, when the tumor became much less tense; and he says on 
raising the tumor up, he saw the Fallopian tube passing from its 
upper part, and thus he knew at once he had punctured the uterus. 
He says : 

" On withdrawing the canula, a soft, spongy, bleeding mass protruded, 
and on putting in my finger to push this back and examine the uterine 
cavity, the anterior wall of the uterus, which was very soft and friable, 
as it had undergone fatty degeneration, gave way along the middle line 
from the puncture (which was near the fundus) for an extent of from 
three to four inches down the body toward the neck. With very slight 
pressure a quantity of liquor aranii and a foetus of about five months 
escaped. I then easily peeled off the placenta from the inner surface of 
the uterus ; the organ did not contract, and there was free bleeding from 
three vessels close beneath the peritoneum at the lower angle of the 
rupture in the uterus. These vessels were secured by three silk liga- 
tures. Oozing still going on from the surface where the placenta was 
attached, I made a free opening into the vagiua by passing my finger 
from above through the cervix and os, and then put a piece of ice into 
the uterus and held it within by firmly grasping the organ, which then 
contracted. I then brought the peritoneal edges of the tear in the 
uterus together by an uninterrupted suture of fine silk, one long end of 
which I had previously passed into the uterine cavity and out through 
the OS into the vagina. By seven or eight points the edges were brought 
accurately together, and the other end of the silk was brought through 
the opening in the abdominal wall, with the ends of the three ligatures 
on the vessels in the uterine wall close to the pedicle, and were tied to 
the clamp." 



634 ABDOMI>-AL OVARIOTOMY. 

The patient completely recovered. 

I am indebted to Dr. INIunde for the following very interestino- 
case, published in the Aa<traJ.ian MediGol Journal, of February, 
1875, by Thomas Hillas, M.E.C.S.,EQg., of Victoria, Australia : 

"Mary McC.aged twenty- four years, single, was admitted to the Bal- 
larat District Hospital, June 4rh, 1872. The history of her case was 
peculiar. She believed that she became pregnant in March, 1871, and, 
not wishing to be confined in the district in which she lived, she sought 
admission to the lying-in ward of the Bailarat Benevolent Asylum. 
She was admitted there in November, 1871, and after staying there 
until the following June, a consultation of the honorary staff was called, 
and she was discharged, her case being deemed ovarian dropsv, and not 
pregnancy. On her admission to the hospital she was examined bv the 
resident surgeon, and subsequently by the honorary surgical and medical 
staff, all agreeing that she was suffering from ovarian dropsy, and that 
it was a suitable case for operation. Oa June 13th, assisted by the hon- 
orary surgeons, Messrs. Nicholson and Whitcomb, and the resident sur- 
geon, Mr. Owen, and the honorary medical staff, the patient being under 
chloroform, I commenced the operation, by an incision midway between 
the umbilicus and pubes. On arriving at the peritoneum, I made a 
small opening into it, when out spurted a large jet of venous blood, which 
the pressure of the finger controlled. I came to the conclusion that I 
had wounded, unwittingly, a gravid uterus, and, feeling sure of this, I 
extended the first incision upward to the umbilicus, when a large uterus 
rolled out on to the thighs, and the ovarian sac protruded. This was 
tapped, and about eleven quarts of fluid were drawn off: there were but 
few adhesions, which were easily broken down, and there was no haemor- 
rhage. The sac contained about a dozen small cysts, but, the external 
wound being large, there was no occasion to tap them. The pedicle was 
short and thick, and, after being tied firmly with a double whipcord 
ligature, the clamp was securely applied, and the pedicle divided, the 
ends of the double ligature being tied over the ends of the clamp. Xow 
came the difficulty. The uterus was all this time lying on the thighs, 
with a foetus in it, and a wound through its muscles, probably into the 
placenta. Some of the bystanders advised that the wound in the uterus 
should be sewn up, and that organ replaced in the abdomen ; but seeing 
that labor must come on soon, and that the rupture of the uterus would 
most likely occur at the seat of injury, I personally decided to perform 
the Csesarean operation as being the most likely means of giving the 
patient a chance to recover. The uterus was incised to about five inches, 
and the placenta and a foetus, alive and well developed, at about the 
eighth month of gestation, extracted. I then stitched up the wound in 
the uterus with about nine or ten silver-wire sutures, carefully tucking 



PREGNANCY WITH THE TUMOR. 635 

the cut ends down into the incision. Immediately on completing this 
the uterus contracted firmly. I then sewed up the wound in the abdo- 
men with deep and superficial stitches, the deep stitches including the 
peritoneum, leaving the clamp at the lower margin of the wound, and a 
good deal dragged upon. The right ovary was the one afl^ected, and the 
patient measured sixty inches around the abdomen before the operation. 
The sac and its contents, after removal, weighed thirteen pounds, and 
are preserved in the hospital dispensary. The patient vomited for about 
forty-eight hours after the operation, having been an hour under chloro- 
form. This was relieved by morphia and ice, and on the fourth day all 
unfavorable symptoms abated. There was a discharge of pus from the 
lower portion of the wound, which ceased in about a fortnight, and then 
completely healed. She was discharged, cured, at the end of six weeks. 
On July 3d, a month after the operation, she menstruated moderately 
for four days, and again on the 28th of August. I have seen her sev- 
eral times since, and she is in perfect health." 

Dr. Alunde also kindly sent me the following three cases which, 
although not exactly corresponding to the cases already reported, 
will doubtless be of interest in this connection. The chances of 
saving the lives of the patients would undoubtedly have been in- 
creased if the operator had, in the first case, removed foetus and 
tumor, instead of leaving both untouched ; and in the second, the tumor 
as well as the child. They will serve as a warning to others not to 
commit the same error : 

" Dr. Erskine Mason reported to the New York Pathological Society in 
1877 the case of a patient, thirty years of age, single, who entered Roose- 
velt Hospital, July 30th, 1877. Since eighteen months increase of ab- 
domen, the circumference of which at umbilicus measured thirty-nine 
inches. A vaginal examination showed the uterus high in the pelvis 
and movable. Distinct fluctuation in abdomen ; area of flatness not 
changed by position of patient. Diagnosis of ovarian cyst confirmed by 
one of the most expert ovariotomists of New York city. Ovariotomy 
was considered indicated. On opening the abdomen a cyst appeared, 
which was opened by the trocar, and eight ounces of fluid evacuated, 
when this cyst was found to be the pregnant uterus. The trocar wound 
was closed by sutures, and the abdominal wound also united. Patient 
gave birth the next day to a six months' foetus. Death of collapse 
eighteen and a half hours after operation. Autopsy showed large mul- 
tilocular cyst of left ovary. Uterus well contracted ; no peritonitis." 

Of the second case. Dr. Munde says : 

" I have looked over Olshausen's recent work on Diseases of the Ova- 
ries, and found mention of only one case of Csesarean section complicated 



636 ABDOMINAL OVARIOTOMY. 

with the presence of an ovarian tumor. The operator was Kob, of Stolp, 
in l!^orth Germany ; the original article appeared in the Transactions of the 
Berlin Obstetrical Society for 1873 ; Beitrdge zur Geburtshulfe unci Gynd- 
kologie, vol. ii, p. 99. I have this work, and abstract the case briefly, as 
follows : 

"Patient forty years; had four children; pregnant near term with 
fifth. Found pelvis occupied by a dense, fluctuating tumor, preventing 
entrance ofthe head. The patient was much debilitated by this presumably 
ovarian growth. Finding the passage of the child impossible through 
the normal pelvis, the tumor was punctured per vaginam, but only thick 
colloid mucus flowed out in small quantities, even after enlargement of 
the puncture with the bistoury. Finally the Csesarean section was per- 
formed, the child extracted alive, and continued to live. The wound 
was closed by thread sutures, and death followed on the third day, prob- 
ably from septic peritonitis. The cyst was not removed, although special 
mention is not made of the necessity (the author probably looked upon 
it as malignant, as colloid tumors were formerly so regarded, and, there- 
fore, thought its removal superfluous) ; but he states that, after the 
operation, colloid matter still escaped from the vaginal puncture. The 
operation was performed January 17th, 1873." 

The third case was reported by Professor Lahs, of Marburg, in 
the Deutsche Med. Wochenschrift, February 2d, 1878 : 

" L. was called to a pluripara in labor presumably eight days; found 
abdomen much enlarged, fluctuation all over; firmly adherent cyst of 
left ovary filling pelvic cavity and obstructing delivery. C^esarean 
section ; three silk sutures in uterus ; cyst too firmly adherent to be re- 
movable. Death from collapse in twenty-four hours." 

In this case no blame can be attached to the operator for not re- 
moving the tumor, the firm adherence of which to the pelvic cavity, 
and the prostration of the patient from her long labor, rendering so 
severe an undertaking unjustifiable. 

Mr. Wells says, with reference to the question : 

"What should be done when a pregnant uterus is discovered during 

some stage of ovariotomy '? Let it alone But supposing the 

operator has penetrated the uterus or wounded it? If any conclusion 
can be drawn from the case in which I made this mistake, and emptied 
the uterus, and two other cases, in which the same mistake was made by 
other surgeons who did not empty the uterus, but closed the puncture 
in its walls by wire sutures, and both patients died after aborting, while 
mine recovered, it would seem to be the safer practice to empty the 
uterus." 



PREGNANCY WITH THE TUMOR. 637 

The soundness of this teaching must receive the sanction of com- 
mon-sense, and is happily confirmed by the result of the two addi- 
tional cases, one published by Mr. Thomas Hillas, of Victoria, and 
the present one by himself. It will also be noticed that the treat- 
ment of the wound in the uterus, and the manner of closing the in- 
cision in that organ, had an important bearing on the subject in all 
three of these successful cases. Mr. Hillas closed the wound with 
interrupted silver sutures; Mr. Wells with an uninterrupted silk 
suture ; while mine was closed with interrupted silk sutures. From 
what I could see of the more immediate effect, as well as from the 
final result, I cannot doubt that this procedure had much to do with 
the recovery of my case. Although Mr. Hillas makes no mention 
of his having secured a free exit for the discharge from the uterus by 
dilating the cervix, it is to be presumed that he did not neglect this 
precaution. Mr. Wells passed his finger down from the cavity 
through the cervix and os, while in my case I opened the cervical 
cavity w^ith a large catheter. I think it is but fair to state that 
while these three cases were treated so essentially alike by all of the 
operators, neither of them was aware that there was any precedent 
for it. I certainly did not remember Mr. Wells's case at the time I 
operated, and I believe Mr. Hillas, like myself, had overlooked it. 

Other considerations bearing upon the question of ovariotomy, as 
advanced phthisis, serious organic disease of the heart or kidneys, or 
malignancy of the tumor, in all or any of these conditions, I would 
refuse to ])erform ovariotomy and resort only to palliative measures. 

We will often meet with cases that have been neglected until pres- 
sure has impaired the nutritive functions to such an extent that the 
recuperative powers of the patient have been greatly reduced. In 
some of these cases we may improve the general condition of the pa- 
tient by tapping the tumor and restoring nutrition by proper meas- 
ures. This should be attempted where there is a cyst from w^hich 
we can reasonably expect to draw off a large quantity of fluid. If, 
however, the distension is caused by the growth of a multilocular 
tumor, with only small or moderately sized cysts, we should risk the 
operation wdthout loss of time or addition of the risk of a fruitless 
tapping. 

When the tumor is not large, or has been reduced by tapping, we 
should resort to tonics, abundant and nutritious diet, and surround 
the patient with the best hygienic conditions possible until her health 
is sufliciently restored to enable her to sustain the effects of the opera- 
tion. 



638 ABDOMINAL OVARIOTOMY. 

There are mental conditions which increase the hazard of an op- 
eration. 

When a patient is very greatly depressed on account of bereave- 
ment, or other causes of intense grief, the indications should be very 
urgent to justify the immediate removal of the tumor; indeed, if it is 
possible, we should allow sufficient time for reaction from such a 
state of depression. I feel sure that I lost one patient because I 
could not pay sufficient attention to this condition. 

Courage on the part of the patient is an important item in assur- 
ing success in ovariotomy, and we should inspire the patient with 
hope by every possible means. The most favorable view of her case 
should be presented to her, and every means taken to help her to ex- 
pect recovery, instead of leaving doubt in her mind. 

The menstrual cycle affi^rds a time when the operation is more 
promising, and I think there is no doubt that we should operate as 
soon as the menstrual flow has subsided, if possible. 

The time of year in this climate is not a matter of so much im- 
portance as in warmer latitudes. 

I would rather operate in the warm than in the cold season, as 
ventilation can be secured much more easily at such times than dur- 
ing the inclemency of the winter season. 

If we can command the time, without serious inconvenience to the 
patient in reference to the size of the tumor, it would be better to 
select a period between the two extremes of temperature. 

The best place for the operation, if the patient has a comfortable 
home, is at her private residence instead of. a hospital, unless it is 
one in which isolation and good ventilation can both be commanded. 

A well-organized special hospital, in consequence of the good atten- 
tion always at hand, is probably the next best place. When the pa- 
tient comes to the city in a good condition for ovariotomy the opera- 
tion should not be delayed lest the health of the patient be dete- 
riorated by the urban or hospital atmosphere. If the operation is to 
be performed in a private house, the room should be selected with a 
view to good ventilation, quietude, and cleanliness. Mere conveni- 
ence is not a sufficient reason for the choice of rooms, as no sacrifice 
is too great if it will insure success. It is hardly necessary to state 
that a good, faithful, and intelligent nurse is indispensable. The care 
of the patient should not be committed to interested relatives unless 
they possess the information requisite for correct treatment. 

The personal supervision of the patient is a matter of the first im- 
portance. All of her functions, especially those of the skin, kid- 



PREPARATION. 639 

neys, and alimentary canal, should be regulated, if they need regula- 
tion, before placing her upon the table. The first by means of a 
warm bath, the second by the administration of some preparation of 
lithium or the acetate of potassium, and the third by the administra- 
tion of a gentle but thorough cathartic; castor oil is ordinarily the 
best. Pleasures should be taken to keep up the action of the skin 
and kidneys. The under-garments should be woollen, and cover the 
patient from the throat to the feet, and enough changes secured to 
keep them clean and fresh, and the secretions encouraged by the 
administration of plenty of fluids, of which cold water is the best. 
The urine must be watched and its quantity and character regulated. 

During the operation the patient should be, as near as practicable, 
covered, her extremities especially, with her woollen garments. 

The personal preparation of the surgeon, assistants, and attendants 
should be equally careful. Perfect cleanliness in them is a matter of 
paramount importance ; to this end, ablution of the hands and cleans- 
ing the nails must be thorough immediately preceding the operation. 
All of the articles used in the operation should also be as clean as 
possible. Every preparation should be made that will conduce to 
the convenience and easy access to every part of the patient by the 
surgeon and the assistants. A table of convenient size, say five feet 
long and twenty inches wide, and high enough to enable the surgeon 
to stand erect, should be placed near an abundant source of good 
light, and yet so that all may pass around it with ease. The table 
should be prepared by covering it with a comforter or blanket, and 
a pillow placed on the end most remote from the light. 

When ready, the patient should be thoroughly etherized, prefer- 
ably in bed, and placed upon the table, her wrapper drawn up close 
under her arms to prevent it from becoming soiled, and the abdomen 
covered with a rubber blanket, with an opening eight or ten inches 
long, and wide enough to permit of the exposure of the most promi- 
nent part of the tumor. 

The surgeon may stand to the right side of the patient, or he may 
cause her to be placed near the end of the table nearest the light, 
with her limbs hanging over the end of the table, each foot resting 
on a stool, and take his position at the foot of the table. This is the 
position I prefer in most cases, as I think it leaves every part of the 
abdomen within easy reach, and the instruments may be placed on 
a table near enough to be entirely at his command. 

The operation may be divided into three stages, and the instru- 
ments necessary to perform it into as many groups. The first is the 



640 



ABDOMINAL OVARIOTOMY. 



exposure of the tumor; second, the removal of the same; and third, 
the cleansing of the peritoneal cavity and closure of the wound. 

For the first we need a scalpel, blunt-pointed bistoury, scissors, a 
grooved directory, a sharp hook, and one or two sponges which have 
been thoroughly cleaned and soaked in water containing two per cent, 
of carbolic acid. For the second and third, a large trocar with rub- 
ber tube, long and large enough to carry the fluid over the side of 
the patient down into a receptacle under the table; a large steel 
sound, scissors, forceps, and thread, with which to arrest haemorrhage; 
two large needles, armed with double-plaited silk ligatures, well 
waxed; clamps, wire ^craseurs, and a half-dozen fine sponges that 
have never been in use, and thoroughly prepared by cleansing and 
carbolizing, and some pieces of fine soft flannel, one-half yard square; 
a half-dozen long, straight needles, armed with long silk ligatures, 
well waxed, and plenty of silk for tying small arteries; lint, several 
rolls of cotton batting, and a binder of fine flannel, long enough and 
large enough to cover all of the dressings. In addition to these, 
there should be plenty of hot and cold water in basins, carbolized 
oil, and a good spray apparatus for use. 

There should be at least four assistants: one to hold the rubber 
cloth and steady the tumor, who may stand at the side of the patient; 



Fig. 160 




another to administer the ether; a third to use the spray, who may 
be situated so that he can direct it on the wound ; and a fourth to 
use the sponges and otherwise assist the operator. 

Before the patient is put under the influence of ether, she should 
empty the bladder, and in default of her having done so, the catheter 
should be so used. 



FIRST STEP. 641 

The spray should be used before the commencemeut of the incisiou, 
and continued during all of the steps of the operation. The incision 
is usually made in the median line, midway between the umbilicus 
and the symphysis pubis. The cut through the integument should 
be from two and a half to three inches long, and that through the 
subjoined aponeurosis and peritoneum only one inch in length. This 
is an exploratory incision, and will enable us to determine the nature 
of the tumor, the extent and firmness of the adhesions, vascularity, 
etc., or whether there is a tumor or not. 

In making the incision, we may cut freely through the skin and 
adipose tissue immediately beneath it. This will expose the aponeu- 
rotic expansion of the abdominal muscles. We now, with a sharp 
hook, lift up a thin layer of this aponeurosis and divide it. If we 
are not in the median line, the edge of the rectus muscle wdll come 
in view. When this is the case, we search for that line by passing 
the grooved director, or the handle of the scalpel, into the sheath, 
first to the right, then to the left, and the instrument will be arrested 
at the border of the muscle, and this points out the location of the 
linea alba. By very light strokes of the knife, or the lifting up of a 
portion of the expanded tendon, we carefully divide it down to a less 
marked, yet usually distinct, layer of adipose tissue. This last is 
generally thin and loose compared with the subcutaneous stratum, 
and lies upon the peritoneum. It should be carefully divided, and 
the peritoneum brought into view. Here the operator pauses until 
all haemorrhage ceases, and, if necessary, twists or ligates small arteries 
or veins which may bleed too freely. These steps in the operation, 
and in fact all others, should be taken Avithout any hurry, and the 
operator should give himself time to thoroughly understand the an- 
atomy of the parts with which he is dealing. 

After the bleeding has ceased the peritoneum should be raised by 
the hook, and divided to an extent sufficient to pass the grooved 
director, upon which the division may be made to the extent of the 
deep portion of the incision. 

There are four sources of possible embarrassment in opening the 
peritoneal cavity. The first and most common is the adhesion of the 
parietal to the visceral layer of the peritoneum covering the tumor. 
This is mure of an embarrassment than danger, as the only harm 
likely to be done may be the opening of the tumor. The next most 
frequent is the presence of the bladder between the tumor and the 
peritoneum, in which case it will require great care to prevent wound- 
ing this viscus. If there is any doubt which the appearance of the 

41 



642 ABDOMINAL OVARIOTOMY. 

parts will not solve, it will be well for some one who is not assisting 
the operator to pass the catheter into that organ. When the bladder 
is found in this position it may be avoided by extending the incision 
upward sufficiently to pass above it. 

The third is the presence of the uterus beneath the incision. The 
use of the sound will enable us to diagnose this circumstance, if it 
has not been done in the examination before the operation. 

The fourth is the presentation of the intestine. We may diagnose 
this by the contents, shape, etc. 

When the peritoneum is divided sometimes ascitic fluid escapes, 
generally small in quantity, but sometimes copious. We should now 
inspect the exposed portion of the tumor. If it is an oligocyst, or 
monocyst, it will present a shining, pearly aspect, with very small ves- 
sels ramifying in its walls. If it belongs to the polycystic variety 
there will often be quite large vessels noticeable ; the pearly aspect 
will be less marked, and sometimes replaced by a livid or red color. 
If it is a uterine tumor it will be of a dull red color, thick aud fleshy 
to the sense of touch. Tumors of the omentum, malignant or other- 
wise, would not answer to this description. 

Second Stej). 

When satisfied that the tumor is ovarian, we should introduce the 
steel sound gently and slowly; pass it over the anterior and lateral 
portions of the tumor, to ascertain whether there are any adhesions ; 
if any, their locality and firmness. Often there svill be some so very 
slight that they will give way as the sound is passed over the tumor. 

The force with which the sound should be applied to these ad- 
hesions must be very slight, as it is not advisable to break up strong 
adhesions in this way. 

Should there be no adhesions discoverable by the sound, the pre- 
sumption is that there are none. Upon this presumption our incision 
may be enlarged to the size of the tegumentary opening. 

If adhesions are large and firm, the whole incision should be in- 
creased until five inches in length. I believe this to be the proper 
time to extend the incision to its required length, because we may the 
better prevent the flow of blood into the peritoneal cavity. Up to 
this time the assistant who steadies the tumor has very little to do; 
but, during the time of the enlargement of the incision and the 
removal of the tumor, he should keep the margins of the wound in 
such close apposition to the surface of the growth that nothing can 
enter the peritoneal cavity. 



SECOND STEP. 



643 



Ovariotomy. 

The second step in the operation consists in the removal of the 
tumor. The large trocar, with a rubber tube attached, so as to lead 



Fig. 161. 




Fitch's Trocar. 



the fluid into a vessel under the table, may now be plunged into the 
cyst at the upper angle of the wound, and so much of the contents 
of the tumor as will pass through the tube be drawn off. 



Fig. 162. 




As the tumor decreases in size the sacs should be seized by hooks, 
the trocar or forceps, or both, as may be necessary, and drawn for- 



644 



ABDOMINAL OVARIOTOMY. 



ward in such manner that the opening in it will be outside the in- 
cision in the abdominal walls. 

In this way there will be less danger, if any, of the contents of 
the tumor escaping into the peritoneal cavity. 



Fl&. 163. 




Nelaton's. 



This part of the operation may be very much facilitated by the 
assistant judiciously pressing upon the abdominal walls. When the 
fluid in the first sac is thus evacuated, another large cyst, if any 
should present itself, may be perforated by the trocar from the cavity 
of the main cyst, and still others consecutively until the size of the 
tumor is small enough to pass through the incision. 

Should the secondaiy cysts be small or their contents so viscid as 
not to pass through the trocar, the opening in the main sac may be 
enlarged sufficiently to admit the fingers or hand with which the 
smaller cysts may be broken up, and their contents evacuated through 
the main opening. While the inside of the sac is thus manipulated, 
the margins of the opening should be drawn out beyond the lips of 
the external wound, and held so that no fluid can enter the abdominal 
cavity. Sometimes the whole of the contents of the tumor will be so 
thick and tenacious that it will not pass through the trocar, when all 
of them may be removed by the hand in this way. 

When possible to break up the internal cysts with the fingers, the 
hand should not be introduced. In doing this part of the operation, 
great care should be taken not to rupture the parent cyst. 

As the tumor is collapsing we must look carefully for adhesions, 
and dispose of them as we meet with them. The omentum may be 
adherent to a part or the entire anterior surface of the tumor. 

If the omental adhesions are extensive they may be overcome by 
insinuatino^ the fino:ersfrom above between thecvst and the omentum 



SECOND STEP. 645 

and carefully separating them. We should endeavor to do this 
without tearing any vessels except at their extremities. After the 
separation we may turn this membrane back out of the wound, and 
allow it to remain there in care of an assistant until the tumor is re- 
moved. If it bleeds much, we may at once tie it as a whole or in 
sections, with fine silk, and return it into the abdomen. If the ad- 
hesions are small, we may lift the adherent portion up and ligate it 
en masse. 

I do not now think it necessary to cut off the ends of the omentum 
below the ligature but return it all. In no case where I have done 
so has any disagreeable results followed. 

Adhesions to the abdominal walls may occupy but a small space 
or they may be quite extensive, and may be in front or lateral por- 
tions of the parietes. 

Long broad fleshy bands sometimes extend from the abdominal 
walls and spread themselves over the front and sides of the tumor. 

These thick fleshy adhesions should always be ligated before they 
are separated from the tumor. 

If the flat adhesions of the surfaces are in front, we are often 
unable to distinguish the peritoneum from other parts, and as a con- 
sequence the tumor is generally laid open in making the abdominal 
incision. The accidental opening is no disadvantage in such cases, 
as it enables us to evacuate the whole of the contents of the tumor 
without the danger of having it flow into the peritoneal cavity. 

In this kind of a case the tumor must be evacuated before the ad- 
hesions are broken up. When the tumor is thus evacuated we may 
overcome the adhesions by introducing the hand into the empty cyst, 
seizing its walls and making traction from within, upon the points of 
adhesion, with sufficient, force to cause them to give way, and if there 
be no visceral adhesions this is quite effective and safe. 

Another method is to extend the incision upward until the boun- 
dary of the adhesions is reached and passed a short distance, then we 
can carefully separate them by the fingers from above downward on 
the outside of the cyst. There is ordinarily some oozing of blood 
from the abraded surfaces, but the contractions of the abdominal 
walls usually arrest it ; if not we may cauterize the bleeding patches 
with the thermal cautery, take up the bloodvessels separately, and 
ligate them, or pass a curved needle, armed with thread, under the 
centre of them, on each side of them, and by drawing the thread, 
thus surrounding the patches, the surface will be puckered like the 
mouth of a purse, compressing the vessels sufficiently to arrest the 



646 ABDOMINAL OVARIOTOMY. 

hsemorrhage ; the thread may then be tied and cnt off. In this way 
all danger from haemorrhage may be avoided. The long broad bands 
of adhesions may be tied in sections with fine thread and cut off close 
to the tumor. 

When it is necessary to introduce the hand into the peritoneal 
cavity for any purpose during the operation it must be thoroughly 
cleansed and dipped in carbolized water. 

As the tumor is being drawn slowly from the abdominal cavity, 
w^e should carefully watch for visceral adhesions. These should 
never be separated by traction, as above described, but the adherent 
portion of the cyst should be cut out with scissors, leaving a large 
marg^in attached to the viscera. 

To secure the patient against the danger of the secretions, which 
might eventuate from the surfaces of these abandoned pieces of cyst, the 
inner membrane should be stripped off by the fingers or forceps. In 
doing this we should retain firm hold on the parts by seizing the 
margins of the adhering patch of the cyst instead of the viscera. 

These directions are intended to apply particularly to visceral ad- 
hesions in the abdominal cavity, and are equally applicable to those 
within the pelvis, provided the adhesions are limited and may be 
easily reached and manipnlated. Unfortunately, however, sometimes 
the tumor adheres with insurmountable firmness to the whole circle 
of the pelvic cavity, uterus, and bladder. In such cases I have no 
hesitancy in preferring enucleation, as taught by Professor Miner, of 
Buffalo. This may be done by cutting or tearing through the ex- 
ternal layer of the cystic walls above the point of adhesion, and 
stripping it off from above downward into the pelvis, the fingers may 
be inserted between the outer and inner layers of the cyst wall, until 
the latter, with the contents of the tumor, is. removed. In this op- 
eration the vessels, arteries, and veins, which ramify in the connective 
tissue adherent to the peritoneal membrane, are not torn to any con- 
siderable extent, and are separated from the enucleated tumor. The 
tumor is turned out of its external envelope, the broad ligament is 
not violated or disturbed; the tumor is removed from the ovary over- 
lying that ligament. Without a knowledge of its anatomy, seeing 
the tumor come out without any pedicle, is calculated to perplex us, 
and we can hardly believe in the completeness of the operation. 

The broad ligament, with the Fallopian tube, ov-arian ligament, 
etc., contained within it, forms the pedicle, when the tumor is lifted 
out in the ordinary operation of ovariotomy, and the vessels pass 



! 



THIRD STEP. 647 

through this to the connective tissue immediately beneath the perito- 
neum, covering tlie tumor. These are all left behind in enucleation. 

The vessels and peritoneal covering are left to contract by their 
own elasticity, and as they are not torn, except where the vessels are 
very small, they do not bleed much. If any vessels bleed after enu- 
cleation they may be ligated separately. 

After the adhesions are overcome and the contents of the tumor 
removed so that it may easily pass through the incision, gentle trac- 
tion will enable us to lift it from the abdominal cavity. One assist- 
ant may support the tumor in such a position that none of its con- 
tents will escape into the pelvic cavity and thus expose the pedicle 
without traction upon it. After carefully Inspecting the pedicle and 
passing the fingers around and along the whole length of it to be as- 
sured that it is perfectly isolated, the operator may pass a large needle, 
armed with a double ligature of strong silk (the braided is the best), 
through the middle of the pedicle, an inch below the tumor, and ligate 
it very firmly on either side. The pedicle may then be divided with 
scissors close to the tumor. The division should be at least three-quar- 
ters of an inch from the ligature, and perhaps an inch would be better. 

If divided too near the ligature there is danger that by retraction 
the stump may be withdrawn from the loop and thus permit hsemor- 
rhage to take place. 

We cannot be too careful in placing the ligature, tying it tightly, 
and leaving the stump sufficiently long. If this part of the opera- 
tion is not properly done there is very great danger that the shock of 
vomiting will loosen the ligature and cause the death of the patient 
by secondary hsemorrhage. 

Before cutting through the pedicle it must be surrounded by a 
napkin at the ligated point to absorb the blood effused from the 
vessels of the tumor, and thus prevent it from passing into the peri- 
toneal cavity. 

Third Step. 

The third step in the operation consists in cleansing the abdominal 
cavity and dressing the w^ound. 

Before proceeding further the operator should examine the contents 
of the pelvis first to ascertain whether there are any bleeding points, 
and secondly to assure himself that the remaining ovary is sound and 
does not require to be removed. If the other ovary has commenced 
the process of cystic degeneration it ought to be isolated by a double 
ligature placed beneath it, and then removed. 



648 ABDOMINAL OVARIOTOMY. 

If there have been adhesions, every point whence haemorrhage is 
likely to occur should be inspected and the haemorrhage checked by 
the means above mentioned. 

As the nuids — blood, serum, ovarian fluids, etc. — usually gravi- 
tate into the pelvis, they may generally be cleaned away by carefully 
sponging that cavity. 

AVith the left hand passed into the pelvis the intestines may be 
lifted up and held out of the way, while with the right the operator 
gently and repeatedly presses the sponge down into the hollow of the 
sacrum, and thus takes up all the clots, fluid, blood, serum, etc. 
When this process is finished the abdominal cavity should again be 
inspected and thoroughly cleansed by the sponges, and before closing 
the wound the ligatures should be cut short, the uterus and stump of 
the pedicle be placed below the intestines in their normal position. 
I think this last precaution of properly replacing the pelvic viscera 
of much importance. Before closing the external incision I lift the 
abdominal walls ofP the viscera and cause the spray to be thrown into 
the cavity of the abdomen to perfectly carbolize it. 

I now close the incision with fine silk sutures about one-half inch 
apart, and passed in half an inch from the margin on the cutaneous sur- 
face so as to penetrate the peritoneum at least one-quai'ter of an inch 
from its cut edge, from the right, and penetrating the other side of the 
incision from within outward at similar points. When the incision is 
accurately closed I cover the wound with a piece of patent lint, sat- 
urated with carbolized oil, large enough to extend beyond the margius 
at least two inches in every direction. 

The wound thus covered is further protected by cotton batting five 
or six inches thick, which extends over the whole abdomen and down 
well upon the symphysis. 

The whole is secured by a flannel binder from the pubis to the 
ensiform cartilage. The spray is continued until the oiled lint is 
placed over the wound. 

This dressing is not according to the Lister method, but I think it 
is quite as effective in keeping out septic particles. 

I have given the reader in detail the method of operating which I 
now employ. Like most other gynaecologists who have practiced 
ovariotomy since 1859, I have performed the operation in many dif- 
ferent ways, but for the last two years I have operated uniformly in 
the manner above described. Every step in the operation, as I now 
perform it, is done in the simplest possible way, and this I think a 
great recommendation. 



THIRD STEP. 649 

I would impress upon my readers the great importance of gentle- 
ness of manipulation. We should not forget, in the excitement of the 
operation that we are handling the abdominal organs, and plunge our 
hands roughly and forcibly into the peritoneal cavity, search for ad- 
hesions, and tear them away violently, heedless of the damage thus 
inflicted. 

I would not think it necessary to so implicitly insist upon gentle- 
ness, if I had not,, on more than one occasion, seen the peritoneal 
cavity, with its contents, submitted to such violence. Above all things 
use no sponge-holder other than the fingers. 

It is only necessary further to say that all the sponges used should 
be new and thoroughly carbolized. The carbolized water for the 
spray should be about three per cent. 



CHAPTEE XLIL 

OVARIOTOMY, CONTINUED. 

Aecidents that may occur during the Operation. 

Unfortunately in some cases of ovarian tumors, the adhesions 
are so extensive and intricate, and the cysts so changed by deposits of 
albuminous and fibrinous accretions, that the anatomy of the growth 
and surrounding organs is confused beyond recognition. The re- 
lations of the viscera and tumor sometimes are so unusual, and so 
contrary to all precedent observation, that the experienced operator 
is sometimes betrayed into mistakes and accidents of a very grave 
character. It will not be out of place therefore to warn the young 
practitioner of what may happen, and what is the best way of manag- 
ing any accidents that may occur. 

When the anterior portion of the cyst is generally and very firmly 
adherent to the peritoneum of the abdominal wall, the inexperienced 
operator will sometimes find himself separating the peritoneum from 
its natural attachments, under the impression that he is breaking up 
adhesions. There are probably very few of us who have not com- 
mitted this mistake to a greater or less extent. This may generally 
be avoided by making the incision long enough to carry the opening 
above the point of adhesion, and then separate it from above. We 
may recognize the accident in its incipiency by turning the lip of the 
wound strongly outward, and inspecting the inner surface of the ab- 
dominal w^all. 

The absence of any but the fascial covering of the muscles will at 
once set us right. If, however, the peritoneum should be separated, 
it is of much less importance than we would expect. In one instance 
I have known several inches of that membrane entirely removed 
without affecting the speedy and perfect recovery of the patient. 

Should this accident occur unwittingly, or in spite of our precautions, 
the membrane should still be separated from the tumor with as little 
injury as })()ssil)le. and when we come to close the incision the interval 
between the membrane and the muscles should be thoroughly cleansed, 
the peritoneum smoothly applied to its natural surface, and included 
in the stitches with which the wound is drawn tntrether. If the 



ACCIDENTS THAT MAY OCCUR DURING THE OPERATION. 651 

membrane is so mutilated that we are in great doubt as to the in- 
tegrity of its structure the worst part may be cut off and removed. 

During incautious separation of adhesions to the liver, spleen, or 
kidney, these organs may be wounded. If the surface thus injured 
does not bleed, we cannot do better, perhaps, than let them entirely 
alone. If, however, hsemorrhage results from the accident and the 
surface is small, we may surround the bleeding space by a fine silk 
ligature, in the manner already directed for similar places in the ab- 
dominal wall. If the surface is so large, however, as to make this 
impracticable, the actual cautery should be used for the purpose of 
closing the vessels. If the pelvic portion of the kidney is torn so 
that the urine flows from it into the abdominal cavity, nothing is 
left for us to do but to extrlpate the injured organ. I know of no 
precedent for this method of managing such a case, but in view of 
the fact that one kidney has been removed for other conditions with- 
out fatal results, I would not hesitate to give my patient the benefit 
of the operation. 

AYounds in the intestinal canal, including the stomach, when there 
is no loss of substance, should be carefully closed with fine silk sutures. 
In closing such openings the stitches should be very near together to 
prevent the escape of fseces. It is also important that the edges 
should be smoothly coaptated, and the mucous membrane pressed into 
the tube to make sure that it does not intervene between the lacerated 
or cut edges of the wound. After an operation attended with this 
accident the peristaltic movement of the bowels should be quieted by 
a liberal and continued administration of opiates for at least ten 
days. The diet should be liquid, and probably beef soup, or beef 
essence would be the best. 

If there is so much loss of substance as to make such a closure 
impracticable, the ends of the gut should, if possible, be brought out 
of the wound to establish an artificial anus. 

By far the most difficult accident (and yet it would seem not 
altogether desperate) to manage, is the wounding of the urinary 
bladder, the gall-bladder, or ureter. When the gall-bladder is 
wounded the only way that we could hope to secure any chance of 
escape would be to stitch it into the wound, — and if necessary the 
wound should be sufficiently elongated, — to insure a temporary dis- 
charge of the bile externally. Of course a perfect cleansing of the 
abdominal cavity of all that fluid, would be indispensable to the 
avoidance of inflammation from its irritating qualities. 

With reference to the lesion of the urinary organs I subjoin an 



652 OVARIOTOMY. 

abstract of a paper read at a meeting of the French Society for the 
Advancement of Science, by Dr. G. Eustache, of Lille [Arch, de 
Tocal, April and May, 1880).* 

" Since such wounds are inflicted only in very complicated cases, 
when there exists widespread, resisting, and vascular adhesions, and 
•when a protracted operation is thus rendered additionally difficult by the 
more or less prolonged contact of urine with the peritoneum and lips of 
the wound, they will indeed become a serious complication. This espe- 
cially, because the already exhausted condition of the patient warrants 
per se a bad prognosis. Such at least is the generally accepted opinion. 
Kow, Eustache, in his last ovariotomy, had the misfortune to make a 
large wound of the bladder, but the patient speedily recovered, notwith- 
standing that the urine had abundantly flowed into the abdominal 
cavity for over an hour. This occurrence suggested to him the idea 
that the prognosis in similar cases might be better than was generally 
admitted, and, provided adequate therapeutic measures were instantly 
adopted, might in future be still ameliorated. Accordingly, the litera- 
ture of the subject was studied, but the information thus gained was 
almost 7iil. The writer, therefore, communicated personally with many 
of the leading ovariotomists, and the answers he received tended to con- 
firm his previous opinion. He then proceeded to communicate what he 
had thus gleaned, and supplements the whole by an analysis of known 
cases. 

" Renal lesions are in the first place considered. The case of Spencer 
Wells is cited, in which a firmly adherent kidney was removed along 
with the ovarian tumor, the patient dying soon after. Three other cases, 
all instances of erroneous diagnosis, are cited. From the records of these 
cases no conclusion can be drawn. Lesions of the ureters are next ex- 
amined. Three cases where one ureter only was wounded are given. 
In each the patient was cured without even the leaving of a urinary 
fistula. All these occurred in Germany. The author was unable 
to find similar instances in the records of the French and English 
surgeons." 

Finally, vesical lesions are disposed of, and the author refers to an 
interesting personal observation elsewhere fully described {Arch, de 
Tocal, July, 1879). Dr. Eustache concludes as follows : 

" 1st. Lesions of the urinary organs during ovariotomy are very rare. 
" 2d. Wounds of the kidney followed by extirpation proved fatal in 
the only case on record. 

* American Journal of Obstetrics, January, 1881. 



ACCIDENTS THAT MAY OCCUR DURING THE OPERATION. 653 

" 3d. Lesion of the ureters was in every case followed by a cure. 

"4th. Vesical lesions were more frequently followed by a cure than 
otherwise. 

" 5th. When the ureter is divided it should be immediately united by 
sutures. Should this prove to be an impossibility the upper end of the 
ureter should be secured in the walls of the bladder. If a uretro- 
abdomiual fistula supervenes, an artificial passage, going from the fistula 
to the bladder, should be established. 

"6th. If the bladder has been opened during an operation, it should 
be immediately sewed up with carbolized catgut, and a self-retaining 
catheter introduced. 

" 7th. If the vesical opening occurs posteriorly (in the vagina), the 
catheter and several cauterizations will suflSce to establish a cure. 

" 8th. In all cases of this kind subsequent treatment must be cau- 
tiously carried out. 

" 9th. Antiseptic dressings generally assure success." 



CHAPTER XLIII. 

OVAKIOTOMY, CONTINUED. 

After-treatment. 

At the close of the operation it will often be found that the cloth- 
ing and person of the patient have become soiled, and it will be neces- 
sary to cleanse her and change the clothing. If the patient is strong, 
and there are no evidences of nervous depression or shock, this may 
be thoroughly but carefully done, and the patient placed in bed. If, 
however, she is cold, and the pulse is weak and quick, and other 
signs of exhaustion show themselves, we would add to her peril by 
too much attention of this kind. When we do not deem it best to 
remove the soiled clothing at once, we should carbolize the soiled 
places, and place dry woollen cloths between them and the skin to 
protect the patient from the chilling effects of the dampness. Bottles 
of warm water should be placed about her feet and limbs, and, in 
marked cases of shock, around the body also. 

The question of administering stimulants must be decided by the 
conditions of the patient, the temperature of the surface, and the 
character of the pulse. If reaction does not take place readily under 
the influence of the warmth and covering, they should be resorted to 
very soon, and may be given by the stomach or rectum, or hypoder- 
mically. Brandy will generally be the best stimulant, but carbonate 
of ammonia or chloroform maybe given until reaction is established. 
As the patient recovers from the influence of the anaesthetic, she will 
generally complain of pain, and will require an anodyne, which should 
be administered without delay in quantities proportionate to the pain. 
The anodyne may be repeated at such intervals and in such doses as 
are necessary to keep the patient free from pain, and no more. 

The room should be darkened, but the windows so arranged as to 
admit an abundance of fresh air. If the weather is cold, the tem- 
perature ought to be maintained by an open grate, if possible, and 
not above sixty degrees (F.). 

Another thing which I think should be insisted upon is, that the 
abdominal muscles be kept in a state of complete rest, by rigid con- 
finement to the dorsal position, until all danger of traumatic perito- 
nitis has passed, that is, for the first four or five days. In general, 



ATTENTION TO THJ5 CLOTHING. 655 

this position will not be very fatiguing if the influence of the ano- 
dyne is maintained to a proper degree. The evacuation of the blad- 
der by the use of the catheter will be one of the means of command- 
ing absolute rest. 

The more fortunate cases will require no other treatment, and by 
good nursing will pass through the convalescence without much in- 
convenience. 

Treatmmt of the Wound, 

Unless something unusual occurs, such as discharge from, or pain 
in the wound, it need not be dressed until the fourth or fifth day. 
The cotton batting and oiled lint may then be removed, and if the 
wound requires no particular attention, both may be replaced by fresh 
material. Generally we will find no signs of inflammation or puru- 
lent discharge, everything looking fresh and solid. The dressing 
should be removed again on the sixth or seventh day, if suppura- 
tion or some kind of discharge does not render it necessary sooner, 
and at this time the stitches may be taken out, the wound cleansed 
with carbolized water, and dressed with adhesive straps so as to give 
support to the abdominal walls. The strip of lint, saturated with 
carbolized oil, should then be placed over the straps and the wound, 
where they cross it. From this time forward the dressing should be 
examined and attended to every second day, and, if need be, every 
day until consolidation is complete, which, when everything goes on 
well, will be in from fourteen to twenty days. During all of this 
time, and for two or three weeks longer, the binder and cotton should 
be continued, the latter gradually made thinner at each dressing until 
it can be omitted. 

Attention to the Clothing, 

When it is possible to put the patient to bed with her clothes clean 
and dry, every care should be taken to keep them so, and no change 
made until the fourth day. After that time, changes can be made 
as often as necessary to preserve cleanliness. It is often difficult, 
when a patient is very weak, to determine how much we may do to- 
ward removing soiled clothing. Remembering that the exertion is 
a cause of further prostration, and that soiled clothing is a source of 
sepsis, the practitioner will be compelled to decide how much the 
patient can bear, and personally supervise all attempts at changing 
the clothing and bed. If it is deemed improper to remove the gar- 
ments which have become soiled, we can do much to avert the dele- 
terious effects, which might otherwise occur, by using carbolic acid 



656 OVA.RIOTOMY. 

freely upon the soiled portions, and placing dry woollen cloths next 
the patient. 

There are two symptoms so frequently met with after ovariotomy, 
apart from any dangerous pathological conditions, that they ought to 
be considered before studying the graver difficulties. While they are 
often not the result of, nor accompanied by, septic fever, nor other 
of the more fatal consequences of ovariotomy, yet, if not arrested or 
properly managed, they may, and sometime do, lead to a fatal ter- 
mination. I allude to vomiting and tympanitis. 

In many instances troublesome nausea and vomiting occur imme- 
diately after the operation. When this is the case it is generally the 
effect of the ansesthetic upon the nerve centres, and it is attended with 
vertigo, and more or less headache. Cold applications to the head 
and a hot water bag to the back of the neck, together with hot brandy 
and water, in small quantities internally, will generally relieve it, 

A hypodermic injection of morphia and atropia, given at the time 
or soon after the operation is finished, will often relieve both the 
pain and vomiting. Sometimes this symptom, arising from this 
cause, will continue for two or three days, and gradually subside ; 
and, when it resists appropriate remedies for twenty-four hours, it 
would be as well to not medicate the patient too much. 

Anodynes. 

When vomiting is caused by the secondary effects of opium, or some 
of its preparations, it is apt to come on the second or third day. The 
opium completely arrests digestion, and the ingesta, except Avhat is 
injected, undergoes chemical decomposition, and the materials thrown 
up are very sour, and have a grass-green appearance. The patient 
is pale, cool, and quiet, though not stupid. The pulse is not changed, 
except, perhaps, weakened. The urine scanty, and ordinarily there 
is an abundant precipitate. This is usually a troublesome form of 
vomiting, and is benefited most by stimulants, as champagne and 
very strong coffee in small quantities. Carbonate of ammonia is often 
very useful. While the patient is fully under the influence of the 
opiate, the vomiting is moderated, if not entirely controlled ; and it 
is sometimes a question whether we continue or withdraw the opium. 
When pain, septic fever, or other such indications exist, I would not 
hesitate to keep the patient under the influence of opium sufficiently 
to relieve the pain and vomiting together by hypodermic administra- 
tion, or the use of suppositories containing morphia. 

The forms of vomiting here mentioned are sometimes so obstinate 



TYMPANITES. 657 

as to make it impossible to administer medicine or nourishment by 
the stomach ; and we often protract the suffering of our patient by 
vain attempts to do so. Generally it will be better practice to ad- 
minister all of these by the rectum and hypodermic injections, and 
allow the stomach complete rest. 

Rectal administrations are so efficacious, when well managed, that 
a patient may be sustained by them for many days. 

Dr. Henry J. Campbell,* of Augusta, Georgia, by some interesting 
experiments, has enabled us to understand why food may be com- 
pletely digested when adminstered per rectum. 

He found that the milk he injected into the rectum of a calf made 
its way up into the small intestines, where it could be mixed with the 
digestive fluids. Milk, eggs, beef essence, finely chopped beef, and 
perhaps other forms of animal food in small quantities, will be re- 
tained and digested in sufficient amounts to sustain the patient until 
the stomach will regain its power of retention. 

Tympanites. 

Until the antiseptic method of conducting surgical operations was 
applied to ovariotomy, tympanites was of very much more common 
occurrence than now. Dr. Peasleef says : 

" Some degree of tympanites usually occurs, even in the simplest cases, 
on the second or third day after ovariotomy, ou account of the diminished 
contractility of the alimentary canal, and in such cases it subsides in the 
course of four or five days under the simplest treatment." 

The conditions which usually give rise to the more obstinate forms, 
when not a complication of general traumatic or septic peritonitis, 
according to Dr. Peaslee, is atony of the intestinal canal, spasmodic 
condition of the sphincter ani, obstruction of the canal by faecal accu- 
mulations, twisting of a convolution of the small intestine, and me- 
chanical obstruction external to the alimentary canal itself. 

As I have just remarked, tympanites from the first of these causes 
occurs as often as before the use of antiseptics. 

Where we have to deal with the second condition a rectal tube 
introduced and kept in the rectum will be sufficient to relieve it. 

The third cause of tympanites is more difficult to diagnose and also 
to manage. If the alimentary canal is well evacuated before the op- 
eration this form will not often occur. When we believe this to be 

* In Gynaecological Transactions. f Ovarian Tumors. 

42 



658 OVARIOTOMY. 

the cause it will be operative onlv when in Gonnection with atony of 
the muscles of the alimentaiy canal, aud may be best relieved by 
stimulating enemata through a long tube, faradization, as practiced 
by Dr. Anthony on one of Mr. Wells's patients, by a tight binder, a 
roller around the abdomen, and, if the stomach is not irritable, by the 
administration of piperine, extract of nux vomica, and belladonna. 
For the fourth variety, or twisting of the alimentary tube, and the 
fifth, obstructions from mechanical causes outside the alimentary 
canal, our resources are very limited, and the means of relief haz- 
ardous. 

These means are the knee-chest position and injections of large 
quantities of hot water, pimcture of the intestinal tube with the 
smallest aspirating needle and opening the wound, thus correcting 
the twisted condition or dislodging the canal from any confinement 
in which it may be placed. 

In continuation of the subject of after-treatment of ovariotomy 
we must consider the more grave accidents and conditions to be met 
with. 

How do these patients usually die? 1st, by shock and collapse ; 
2d, hemorrhage; 3d, acute (traumatic) peritonitis; 4th, septicaemia, 
complicated or not, with tympanites. 

Shock or nervous depression is almost always manifested at the 
close of the operation, and is marked by palene-s of the surface. 
feebleness, and generally quickness of the pulse. ■ ::: ^ ^ : : _ : :. 
and sometimes entire inability to move. The nervous depression 
passes into exhaustion, and death, in some instances, follows within a 
few hotirs ; while in other cases the patient may linger in a state of 
depression for three or four days, and then die from no apparent 
cause except the continuation of the shock. 

In the most profound cases of shock we should apply dry heat 
externally to as great a degree as the patient can bear, and keep her 
as still as possible, remembering that every movement adds to the 
exhaustion. The heat may be applied by a large number of hot 
bricks, stones, and irons. 

They should ]>e applied the whole length of the patient, to the feet, 
legs, trunk, arms, shoulders, and head, and at the same time the tem- 
perature of the room should be raised. Applications of heat to the 
head is of more importance probably than anywhere else, for stimu- 
lating the brain will often arouse the whole nervous system and dispel 
the symptoms. 

The most effective way to do this is by using Thornton's (or its 



[ 



HEMORRHAGE. G59 

modification) cap, and passing hot water through it instead of cold. 
Plenty of warm covering will be necessary, of course, and if the 
stomach is not irritable the patient should drink as much hot water 
as she can. I am quite sure that the vigorous application of heat in 
this way is much more effective than alcoholic or other medical 
stimulants. These, however, may be added and administered by the 
stomach, rectum, or hypodermically. If the depression succeeding 

Fig. 164. 




Modified Thornton Cap. 

the shock should last and be threatening in degree the heat should 
be continued; nourishment and internal stimulants administered per- 
severingly until reaction is established. 

Haemorrhage 

Is said to proceed from the following different sources : 1st. From 
the pedicle in consequence of the imperfect application of the ligature, 
or the retraction of the tissues included in its grasp, so that it becomes 
loosened. 2d. From wounded surfaces left by the separation of ad- 
hesions. This last is not often fatal as a haemorrhage, but it may 
become so in rare instances. The blood derived from this source is 
however apt to decompose and cause septicaemia. 3d. From rupture 
of a plexus of veins near the ligature or elsewhere in the pelvis. Dr. 
Peaslee lost a patient from hsemorrhage, and on a post-mortem exam- 
ination found that it proceeded from this source. He also speaks of 
others. 4th. In certain conditions of the blood predisposing to 
haemorrhage, the blood from the inner portion of the incision finds 
its way into the abdominal cavity in considerable quantities. 

I met with an instance where haemorrhage from the wound im- 
mediately under the skin, the blood escaping outside, gave me a great 
deal of trouble. In this case the blood was so changed that coagu- 
lation did not occur after standing ten hours, and astringents locally 



660 OVARIOTOMY. 

applied failed to stop the haemorrhage, and the only way it was ar- 
rested was by putting pins through the lips of the wound half an 
inch apart, and plugging the wound tightly in the interspaces. 5th. 
From an artery perforated by a needle used in closing the wound 
(Wells). 6th. From the patulous extremity of the Fallopian tube. 

In all of these conditions haemorrhage may follow the operation 
immediately or occur any time during the convalescence. Succus- 
siou from coughing, straining to vomit, moving about too much, 
mental excitement, may all contribute to start up haemorrhage when 
the predisposing conditions exist. When the haemorrhage takes 
place from the pedicle or ruptured veins, the symptoms generally 
appear suddenly and are marked in character. They need not be 
enumerated here, because they are so familiar ; but where the haem- 
orrhage goes on slowly from abraded surfaces the symptoms are 
sometimes very obscure. Increasing rapidity and weakness of the 
pulse, paleness of the face, coldness of the extremities, profuse perspi- 
ration, nausea, and vomiting coming on any time after the first 
twelve hours when not preceded by evidence of shock, are symp- 
toms which point strongly to this accident. 

When the symptoms of haemorrhage become marked, there is but 
one sure way of giving the patient a chance for her life, and that is, 
to open the wound, explore for the course of the haemorrhage, and 
ligate the vessels or bleeding points when found. The abdomen 
should be very carefully cleansed of the blood. 

Judging from the experience of Clay, Wells, Koeberle, and Atlee, 
this second opening of the abdomen is reasonably safe. 

Traumatic Peritonitis. 

Peritonitis, caused by opening the abdomen, judging from my own 
observations, as well as the reports of others, is not very common, 
and has become less so since the antiseptic vapor and dressing have 
come into so general use. At a time when our experience was 
small, compared with what it now is, this was the most feared of all 
the consequences of the operation. This fear was founded upon the 
well-known fact of the fatality resulting from accidental peritoneal 
wounds. 

Fortunately, however, the peritoneum, in cases requiring ovariot- 
omy, has lost much of the susceptibility to inflammation which it 
possesses in a healthy condition. The long-continued distension, 
friction, and frequent inflammations, to which it has been subjected, 



TRAUMATIC PERITONITIS. 661 

SO modify its structure as to greatly alter its appearances, and in al- 
most all instances to reduce its tendency to inflammatory processes 
very much. Hence we expect oftentimes to escape this very danger- 
ous affection. When it does come, it makes its appearance within 
the forty-eight hours immediately succeeding the operation. Its 
symptoms are pain, tenderness, and tumefaction of the lower part of 
the abdomen, frequent pulse, and elevation of the temperature. In 
unfavorable cases these symptoms rapidly increase until the abdo- 
men is largely distended and very tender; the pulse rises to 130 to 
150, or even 160; the heat increases as high as 106 degrees. Mental 
disturbances become a prominent feature toward the close. These 
cases often run their course to a fatal termination in two or three 
days from the beginning. The temperature and the pulse are the 
best guides to the intensity of the inflammation. When the former 
does not rise above 103 degrees, and the latter above 120 per minute, 
we may have a reasonable hope of recovery. 

The objects in the treatment of this form of peritonitis are to curb 
the rapidity of the pulse, reduce the temperature, and control pain. 
Opium in large doses, commenced at once and continued to deep nar- 
cotism, will go a great way toward accomplishing all of these objects. 
I believe that this treatment, at the very inception, will sometimes at 
once break the force of the attack. After the first forty-eight hours, 
or even sooner, large doses of quinine may be added to the opiate 
treatment, when the opium should be slowly withdrawn and brandy 
substituted for it. The quinine, however, should be continued. 

These remedies, quinine and brandy, arrest the waste which follows 
the first stage. With these, nourishment should be pushed to the 
capacity of the stomach and rectum. When there is vomiting, these 
remedies may be given hypodermically and per rectum. Ice and 
ice-cold water may be allowed as desired, according to the craving of 
the patient. Thornton's cap will be of great service in these cases 
also, as the cold water circulating through it will greatly reduce the 
general temperature. A question of great importance is. What ap- 
plications shall be made to the abdomen? In the first two days, if 
the temperature is high, I should have no hesitancy in applying cold 
by means of the water-bag ; but I should promptly change from this 
to warm applications after the stage of effusion had passed, about the 
third day of the disease. 



662 OVARIOTOMY. 



Septicoeniia. 



This is another of the formidable and fatal sequences of ovariot- 
omy. As the operation is now performed, — that is, with antiseptic 
precautions, — it may generally be avoided. 

The cause of septicaemia is the retention, decomposition, and absorp- 
tion of fluids from the sac or sacs of the tumor, or from extravasated 
blood. The observations of numerous operators have established the 
fact that the retention of these fluids does not always result in septic 
fever, because they do not always undergo decomposition; especially 
is this the case, as before intimated, if the antiseptic precautions have 
been faithfully and sufficiently carried out. When it does occur, it 
may follow the reaction which succeeds the protracted depression of 
shock ; but when not occurring in this way, it comes on in from four 
to seven, and even ten, days after the operation. Its course is vari- 
able, terminating sometimes in five or six days, especially when com- 
plicated, and this, I think, rather a frequent thing with peritonitis; 
while in the simple form it may last for ten or twenty days, or even 
longer, before wearing the patient out or merging into convalescence. 

The prognosis, although bad, is not absolutely desperate. Some- 
times the attack is sudden, inaugurated by a chill, and succeeded by 
a rise of temperature and accelerated pulse; or it may be established 
in a very gradual manner, the pulse and temperature rising slowly. 
They are generally both much higher in the after-part of the day. 
Derangement of particular organs is not uniform. The skin, some- 
times dry and hot, is often bathed in a copious perspiration, the per- 
spired fluid being sometimes very thin and watery, and again quite 
viscid and sticky. The stomach may or may not be disturbed, but 
generally the rest of the alimentary canal is more or less irritated, and 
diarrhoea, with profuse, thin, stinking stools, is often a marked feature 
of septicaemia. Nervous excitement and delirium, or somnolence and 
apathy, form parts of the symptoms in different cases. In many 
instances great tympanites, with or without peritonitis, add to this 
mischief. In the course of the disease, the circulating fluid some- 
times becomes decomposed to such an extent as to pass easily out of 
the capillaries, giving rise to maculae, blebs, and bullae, or appearing 
in the urine or dejecta from the bowels, or exuding from the exposed 
mucous membrane in the mouth or nostrils. More frequently, how- 
ever, the disease runs its course rapidly when a very quick pulse, 
from 120 upward, high temperature, from 104 degrees upward, de- 
lirium, excitement, or somnolence, and apathy constitute the import- 



TREATMENT. 663 

ant and noticeable symptoms. In either the slow or rapid case the 
stomach will not digest the food taken, and the lacteals will not 
absorb the material exposed to their action. Sanguification is ar- 
rested, and the scorching temperature is maintained by combustion 
of the material in the blood, which ought to sustain the vital func- 
tions. The patient is soon exhausted under this rapid waste, being 
incapable of appropriating anything with which to supply the de- 
ficiency. 

Treatment. 

The most important item in the treatment of septicaemia arising 
after ovariotomy is to remove the cause. This, as has already been 
said, is decomposing substances in the peritoneal cavity. In almost 
all cases the decomposing substances, serum, blood, etc., gravitate to 
the bottom of the cul-de-sac of Douglas, where we can reach it. 
The fluid can usually be detected per vaginam, but sometimes the 
quantity is so small as not to be appreciable by such an examination. 
In either case we should open the peritoneal cavity through the 
vagina, introduce a drainage-tube, and wash out the pelvic cavity 
with warm carbolized water. We may open the peritoneal cavity by 
means of scissors. The patient may be turned upon her side, Sims's 
speculum introduced, and the posterior wall of the vagina lifted up 
by a hook and perforated. The opening in the vagina should be in 
the median line as nearly as possible. The incision should be large 
enough to admit a good-sized tube. Through this the fluid will 
escape, and we may throw carbolized water into the pelvis. We may 
also perforate the posterior vaginal wall with a trocar. This may be 
done very easily when the quantity of fluid is considerable and the 
retrouterine pouch well distended. If opened in this way the first 
washing may be done through the canula before it is withdrawn, 
after which a tube should be passed through the canula, and as the 
latter is withdrawn the former is retained, or we may remove the two 
lower stitches and introduce the drainage-tube through the lower end 
of the wound. 

The cleansing of the abdominal cavity will require repetition in 
proportion to the amount of decomposing materials. Of course no 
one would think of performing this operation until septic fever is 
evident. When this is the case the risk of evacuating the fluid and 
cleansing the pelvic cavity ought certainly to be considered a neces- 
sity, and when indicated it is worth more than all the remedies we 
can bring to bear in the treatment. The rest of the treatment has for 
its object the relief of symptoms, preventing waste, and introducing 



Q6i OVARIOTOMY. 

as much nourishment as can be borne by the stomach, rectum, or 
both, and hypodermically. 

Probably the most important symptom to be attended to is the 
high temperature. This may be combated by cold externally ap- 
plied or administered internally. Cold can be very effectually 
applied to the head by means of the ice-cap invented by Mr. Thorn- 
ton, of the Samaritan Hospital. It is very highly recommended by 
Mr. Wells. It is a coil of rubber tubing so arranged as to fit the 
head like a cap, and when applied to the head the tube is filled with 
ice-water, and one end is placed in a bucket of ice-water very slightly 
elevated above the head of the patient, while the other end is passed 
into a tub under the bed or elsewhere."^ 

By elevating and depressing the two ends of the tube the water 
may be made to run more or less swiftly through the portion forming 
the cap as we may desire. If this cap cannot be commanded, india- 
rubber bags filled with ice-water, or a large beefs bladder, or ice in- 
closed in rubber cloth or oiled silk may be substituted. 

Cold may thus be applied with sufficient intensity to lessen the heat 
of the entire body in a very short time, and I think is very much to 
be preferred to any general application of cold however made. 

Quinine administered in large quantities is very efficient in re- 
ducing temperature and preventing waste ; so also is alcohol. Five 
grains of quinine every four hours, or ten grains every eight hours, 
is the proper dose. Brandy in ounce doses every two hours may be 
given for a like purpose. If tympanites or peritonitis, or both, com- 
plicate the fever, there are local means for their treatment, as else- 
where detailed. 

Remarks and Personal Statistics. 

I am among those who believe in antiseptic surgery. My opera- 
tions date back to 1861, when everything in connection with ovari- 
otomy was in an unsettled state. It is true that there is not perfect 
accord among ovariotomists at the present time, but we have had a 
great deal of experience in different methods of procedure, in the 
several steps of the operation and after-treatment, and can conse- 
quently more intelligently estimate them ; and I think it safe to say 
that the antiseptic process has about done away with the clamp and 
primary drainage; in fact, both of them are incompatible with a 
complete antiseptic dressing. 

^ See modification of it on page 659. 



I 



REMARKS AND PERSONAL STATISTICS. 665 

My convictions as to the benefit of the antiseptic processes in 
ovariotomy are grounded upon ray own experience more than gen- 
eral statistics, although I think the latter are sufficiently convincing. 

I have only operated eighty-two times, and in accordance with the 
experience of other ov^ariotomists my success grows with the number 
of my operations. Before I commenced the use of the antiseptic 
spray and dressing my successes, taking the whole together, did not 
exceed sixty-six per cent. Since I have been operating as I now do 
I have had about eighty-six per cent, of recoveries. The general 
conditions are, it is true, somewhat more favorable now than before, 
and may have had something to do with the favorable termination 
of my cases. Of the twenty-two cases operated upon antiseptically, 
eighteen operations were performed in a small hos^^ital (Woman's 
Hospital of the State of Illinois), surrounded by every favorable 
circumstance at our command. The three deaths all occurred in the 
hospital. The other four cases were in small cities in this State. 
Whether the improved circumstances would have been sufficient to 
give the more favorable results than formerly without the antiseptic 
measures, I am of course unable positively to assert. Neither can 
I say how much may be due to increased skill acquired from expe- 
rience in operating. The number of cases I know are also too small 
to base conclusions upon. AVhile there has been a very marked 
change for the better since adopting the antiseptic method, I think 
my mind has been influenced in coming to a conclusion favoring 
antiseptic practice by the appearance of the wound. So far as the 
wound is concerned there is no question about the effects of the 
dressing. When properly managed there is no smell, no pus, and 
no ulceration. It heals without any evidence of decreased vitality 
in the part. In expressing my belief in the efficacy of antiseptic 
processes in surgery I do not announce any opinion of the modus 
operandi. 1 am not sure that there are septic particles that fall upon 
and induce ferment in the wounded parts, or living germs or ova that 
infest, breed, and diffuse themselves in such numbers as to destroy 
the vitality of the points of attack, and gaining access to the vessels 
disintegrate the circulating fluid so that it is not fit to support the 
vital forces, and that the carbolic acid operates by consuming these 
deleterious particles. But I do believe that the vapor and fluid con- 
taining this substance when used so as to shut out the atmospheric 
air from the abdominal wound adds greatly to our means of avoiding 
one if not more of the untoward conditions sometimes experienced 
after ovariotomy. 



CHAPTER XLIV. 

FALLOPIAN TUBES. 

The Fallopian tubes are sometimes absent ; this is the case gen- 
erally when the uterus is absent. But, according to Rokitansky, 
they are not always wanting when the uterus is. One, or even both 
of them, may be wanting when there is no other fault in the genital 
organs. Occasionally they are met with of diminutive or rudimen- 
tary size. They are also deformed, having two sets of fimbrillse, one 
at the end and the other nearer the uterus, with openings at both 
places ; or bifurcated, the branches entering the uterus at diiferent 
points. Or one may be longer than usual, and enter the cervical 
portion of the uterus as mentioned and described by Pole, and quoted 
by Scanzoni. They are often displaced with the uterus and with the 
ovaries, and, with the latter organs, are found to enter into the forma- 
tion of a hernia. 

Inflammation of the Fallopian tube is, probably, not an unfrequent 
affection, but almost always it is but a small part of the disease that 
exists in its locality ; inflammation of the uterus, peritoneum, locally 
or generally, and ovaritis being separately or collectively connected 
with it, and by their symptoms making the manifestation of disease 
in the tubes. In such cases it is not only impossible, but is of no 
importance, to diagnosticate salpingitis. If the diagnosis could be 
made, it would not influence the treatment. Involved, as they are, 
in the inflammation of surrounding organs, they are occasionally 
destroyed by suppuration, or constricted by bands of fibrin, and the 
tubal cavity is obliterated by exudations. They also' are the subjects 
of catarrhal inflammation, discovered after the death of the patient, 
associated with endometritis, seldom as an independent affection. 

The tubes are doubtless the channel through which inflammation of 
the uterus finds its way into the peritoneal cavity, and also the con- 
duit for fluids — pus, blood, mucus, etc. — from the uterus to the peri- 
toneal cavity. As they are not seldom found dilated so as to admit 
a uterine sound to pass them, — Hildebrant, Mathew Duncan, Thomas 
Budd, and others, have seen and diagnosticated dilatation of the 
Fallopian tube during life, — we need not be surprised at the transi- 
tion of fluids through them in both directions. Thus the serous con- 



FALLOPIAN TUBES. 667 

tents of the peritoneal cavity may be passed into the uterus and 
vagina. The reader will not fail to see the importance of diseases of 
the tubes, on account of the sterility that would result from oblitera- 
tion or constriction of them, or the danger from a too free communi- 
cation between tlie peritoneal sac and the uterine cavity. 

Cancer of the Fallopian tubes is not often observed independent of 
the existence of the same disease in the surrounding tissue. They 
are generally though necessarily involved in cancerous degeneration 
of the ovary and the uterus. 

Hypertrophy and atrophy of them accompany the same changes in 
the uterus. They are enlarged when the uterus is by tumor, inflam- 
mation, congestion, or pregnancy, and become atrophied as the uterus 
diminishes in size, in old age or from any other cause. Dropsy of 
the tubes is occasionally observed. Obliteration of the cavity near 
each extremity leaves the portion of the tube between these points 
free to receive exudation from the lining membrane, which cannot 
find its way out. The fluid accumulates and fills the isolated portion 
of the tube, which continues to increase until it becomes a cyst from 
the size of the finger to that of an orange, and perhaps even larger. 

Dr. C. S. Ward presented a specimen to the New York Obstetric 
Society of double tubal dropsy, the size of a pullet's Qgg. August, 
1871, Journal of Obstetrics. 

We also meet with small serous cysts attached to the fimbriated 
extremity of the Fallopian tube. They are usually small cysts, dis- 
tended by serum, scarcely ever exceeding the size of the finger's end. 



CHAPTEK XLV. 

COCCYGODYNIA, COCCYALGIA. 

Neuralgia of the Coccyx. 

These terms are used to denominate one of the several peculiar 
neuroses of the pelvic organs, especially those situated at the bottom of 
the excavation. It belongs, I think, clearly to the same class of 
cases as vaginismus, urethrismus, spasm of the bladder, rectum, etc., 
and is purely a nervous affection. 

They are all peculiar hypersesthesias, and sometimes have a demon- 
strable basis of excito-motor origin, as fissures, ulcers, inflammation, 
etc., while in other instances there seems to be no material change in 
any of the organs. 

That coccygodynia, like vaginismus, is often associated with uterine 
disease, disease of the rectum, bladder, urethra, etc., is certain from 
observation. Whether these more common affections, after continu- 
ing a long time, may excite the nerves into a state of instability that 
becomes permanent or not, is a question worth asking in this con- 
nection. In common with other nervous affections having a reflex 
origin, may not the symptoms become a disease, and remain an inde- 
pendent affection after the excito-reflex cause has been removed ? 
The irritation so protracted and unremitting I think may and often 
does induce organic change in the nerves or the subordinate centres 
with which they are connected, and thus perpetuate the symptoms. 

Structure Affected. 

There was, in all cases I have examined, room to doubt the exact 
tissue affected, whether in the periosteum, interosseous ligaments, 
muscles, or nerves. 

Symptoms. 

Pain on moving the coccygeal bone, in sitting down, rising up, 
passing the faeces, coughing, sneezing, walking, or standing. In bad 
cases the patients are not able to sit, stand, or walk without great dis- 
comfort, and are so pained by the sitting or erect posture that they 
are confined to recumbency. 

They thus lose their general health and become permanent invalids. 



DIAGNOSIS — PROGNOSIS — TREATMENT. 669 

This is very rare, however, and the most of the cases we meet with 
are in patients who enjoy a tolerable state of general health, but are 
continually annoyed by everything that causes contractions of the 
muscles inserted to the coccyx or closely connected with them. They 
sit on one side of the buttocks or on cushions that remove the pres- 
sure from the coccyx. They rise to the standing position with great 
care, and must be very guarded in walking, coughing, or sneezing, etc. 

Diagnosis. 

This is made by considering the history of the case and by physical 
examinations. The finger passed into the vagina or rectum, and 
pressed backw^ard upon the coccyx, so as to move it, gives the patient 
great pain. Pressure exerted upon the posterior surface, with suf- 
ficient force to move it, causes even greater pain. When the dis- 
ease is severe the suffering is so great that it is with difficulty we can 
examine the coccyx as to its mobility. 

Dr. Jenks says that when a patient is examined under the influ- 
ence of ether the muscles connected with the coccyx are relaxed, 
while they are very strongly contracted w^hen the patient is not ether- 
ized. 

Prognosis. 

There seems to be very little tendency to spontaneous subsidence 
of coccygodynia. 

The menopause does not affect it as it does most of the pelvic dis- 
eases, and it is often a long time after the change of life before the 
patient recovers. It occurs in the young nulliparous and parous 
women alike, but not in the senile. It generally causes more suffer- 
ing in women who are bearing children. 

Treoiment 

The palliation of the symptoms in coccygodynia consists in the 
use of anodynes and tonics, the former to relieve the great suffering 
for the time. They may be used in suppositories per rectum, per 
vaginam, or hypodermically. We can add greatly to the comfort of 
the patients also by contriving cushions or easy chairs for them. 

A tonic or roborant course of treatment will sometimes brace up 
her nervous system so that the patient can bear her ills without 
breaking down physically. Among the means to accomplish this 
end, when the patient is not too bad, travel is of great service, a 
change of climate from hot to cold in the summer, and from cold to 



670 COCCYGODYNIA — COCCYALGIA. 

warm in the winter. Quinine and iron administered internally, 
with liberal and systematic feeding, contribute to the same purpose. 

In the earlier periods of coccygodynia we may hope to arrive at a 
cure by searching for and removing all disorders in the neighbor- 
hood, founding our treatment upon the idea of removing the excito- 
reflex centre of disturbance. 

Dr. Robert Barnes, of London, believes that it is caused by retro- 
versions of the uterus. Anal fissures, haemorrhoids, ulcers in the rec- 
tum, should command our special attention if they exist, and every 
pains should be taken to restore all deviations from general health. 

After the disease has existed long enough to become an inde- 
pendent affection, probably nothing short of a surgical operation will 
result in a cure. 

To the late Dr. IlTott belongs the credit of first describing this dis- 
ease and devising a surgical operation for its cure. He called it 
neuralgia of the coccyx, and, after trying all other measures that 
occurred to him, extirpated the bone. His operation consisted in 
cutting through the attachments of the bone on each side, from the 
base to the apex, everting it and dislocating it from the sacrum. 

This may best be done by incising the integument in the central 
line, and raising and turning aside the flaps until both margins of 
the bone are exposed. The next step is to cut carefully down 
through attachments at the point of the coccyx and introduce a 
blunt-pointed bistoury, or the point of scissors, and separate the 
attachments upward to the base on both sides. The bone can then 
be lifted up and turned backward to expose the articulation, which 
may be divided by a bone forceps or a strong knife. The loose cel- 
lular tissue, on the inner surface of the bone, easily gives way as it is 
lifted from its bed, or may be divided by the knife. 

There is generally very little haemorrhage, and the bleeding will 
in a few minutes subside. All that remains to be done is to close 
the wound by replacing the flaps and joining them by four or five 
stitches. 

This is neither a dangerous nor a difficult operation, and is very 
efiPective in a curative point of view. 

In 1858 Professor James Y. Simpson, apparently with knowledge 
of Dr. Nott's description of the operation for this affection, published 
in the London Medical Gazette his lectures on the diseases of women, 
in which the disease is recognized and his operation described. His 
operation consists in the subcutaneous division of the connections of 
the bone without removing it. 



CHAPTEE XLVL 

ELECTRICITY. 

Electricity has been used in the treatment of diseases of women, 
and with considerable success. All forms have been used, viz., 
static, galvanic, and faradic. Static electricity may be conveniently 
obtained by Holtz's electrical machine. The prime conductor fur- 
nishes positive and the rubber negative fluid. The modes of appli- 
cation are various. Sparks may be sent directly through the tissues, 
or the patient may be insulated and be filled from either electrode, 
when sparks may be drawn through the part affected by presenting 
to it a metallic conductor. A surface thus acted upon will present 
points of irritation. In chronic ovarian difficulties such an applica- 
tion would be suggested. 

Galvanic electricity is best obtained from the galvanic machine, 
which may contain any number of cells, made of zinc and copper, or 
platinized silver or carbon, and a proper fluid to excite chemical 
action. Upon the latter will depend the quantity of electricity, while 
its intensity will depend upon the number of elements undergoing 
chemical action. Of galvanic batteries there are many forms. One 
that is constant and easily kept in order is desirable. 

Faradic electricity differs from both the static and galvanic in this, 
that the faradic current is induced, and is a to-and-fro current, going 
both ways. Its tension is also greater, and current is broken slowly 
or rapidly as one desires by the rheotome of the electro-magnetic 
machine, from which the current is derived. It differs from the 
galvanic current in this, that the latter is unbroken, that is, it is a 
constant current. 

In using electricity a few things are necessary: first, proper in- 
struments, and a knowledge of a few simple facts. A moist surface 
or tissue is always a better conductor of the fluid than dry tissue or 
a dry surface. 

The most succulent tissues present the least resistance to the cur- 
rent. Thus, for instance, bones and nerves are poorer conductors 
than the muscles, and a dry skin will resist the current still more. 
In view of this fact, we wet the electrodes before applying them to 
the skin. 



672 ELECTRICITY. 

The galvanic current, by reason of its constancy, is the most pene- 
trating form of electricity. It is also the most diffusive, for its 
presence is often discernible at points not between the electrodes. 
Of late we have heard much of electrolysis. "What is it? If we 
place the poles of a galvanic battery near one another in a basin of 
water, bubbles will appear, due to the decomposition of the water by 
the current. This action is called electrolysis. We need only attach 
the wires to insulated needles and pass them into fluids within the 
body to decompose them also. We may thus decompose the tissues 
of the body, and in the process the alkalies will appear at the nega- 
tive and the acids at the positive pole. 

Electrolysis then is the decomposition by electricity of either fluids 
or solids. After being thus acted upon these elements are supposed 
to undergo absorption. Electrolysis of ovarian cysts has been suc- 
cessfully practiced. Dr. Frederick Semeleder, of Mexico, claims to 
have thus cured the disease. His enthusiasm led to the publication 
of the facts in 1875, and to the premature assertion of "no more 
ovariotomy.'' In 1874, Fieber, of Vienna, reported two successful 
cases by this method, which, however, seems to have been original 
with Dr. J. F. Biihring, who announced it in 1848. The method 
has been well tried in New York, and unsuccessfully {Gyncecological 
Transactions, vol. ii, 1877). 

The method necessitates the introduction, through the abdominal 
wall, into the cyst of one or more needles for the conveyance of the 
current. This simple procedure may permit of subsequent leakage, 
peritonitis, and death, and is especially dangerous in multilocular cysts. 
The method, notwithstanding it may cure unilocular cysts, is scarcely 
less dangerous than ovariotomy at the present day. The method is 
seriously objectionable in practice, inasmuch as it is not always pos- 
sible to say positively that a cyst is or is not multiple. 

For solid fibroids of the uterus these objections are not applicable, 
and the mere introduction of proper needles is tolerably safe. Dr. 
Ephriam Cutter, of Boston, has thus treated uterine fibroids suc- 
cessfully. 

If the electrical current is passed through a wire, platinum for 
example, which offers considerable resistance, the current will raise 
the temperature of the wire even to a white heat. This is a simple 
galvanic cautery. With it we may cut away tissues or divide them. 
The electro-cautery has been found very useful for the removal of 
the cervix when the site of malignant disease. It is an admirable 
method of removing uterine polypi. 



ELECTRICITY. 673 

An exhaustive paper on this subject by Dr. John Byrne may be 
found in the GyiKxcoJogical Transactions, vol. ii, 1877. The same 
gentleman uses the electro-cautery for kolpocystotomy, burning an 
opening in the base of the female bladder where drainage is desirable. 
See a paper on the subject, Gync^cological Transactions, vol. iv, 1880. 
The advantages of surgery done in this way, are that there is less 
risk of haemorrhage, and openings are not so liable to heal up rapidly. 
The disadvantages are the time consumed, the uncertainty of batte- 
ries, and the fuss. 

The physiological phenomena produced by electricity vary with 
the kind used, also with the quantity and tension, also with the posi- 
tion of the poles, and also as to the tissues acted upon. Ascending 
currents excite as they reverse the natural nerve current. Descending 
currents soothe as they flow with the nerve current. The former 
affect the sensory nerves, while the latter affect specially the motor 
nerves. Upward currents increase reflex action, while downward 
currents diminish it. 

A constant current passed through a muscle produces contraction, 
from the positive toward the negative pole, and drives the blood in 
the same direction. Reverse the position of the poles, and the con- 
traction of tissue is in the reverse direction and circulation is re- 
tarded. If you occasionally break the current by any method, you 
shock the muscle, give it a spasm, the bloodvessels also contract and 
the blood is propelled forward and diminished momentarily in the 
muscle. But observe, the muscle has been exercised. If instead of 
breaking the galvanic current you apply the faradic, the result is the 
same. The galvanic and faradic currents are tonic. They exhila- 
rate, raise the temperature, increase the circulation of the blood and 
enliven the brain. They produce sleep, increase digestion and appe- 
tite. When locally applied they increase the nutrition of the part. 

Descending currents act on the motor nerves, contracting the mus- 
cles, but give pain by their action on the sensory nerves. Ascending 
currents excite the spinal cord and increase reflex functions. By 
these currents, applied by electrodes, we may increase or diminish the 
blood in a given part, exercise the muscles, singly or in groups, and 
excite the sensory nerves. By these currents constipation may be 
relieved. The circulation may be equalized, and hysteria, melan- 
cholia, dyspepsia, and other symptoms of nervous exhaustion, so 
common in women, may be successfully treated by general electriza- 
tion. 

As already intimated the muscles under the influence of the faradic 

43 



674 ELECTRICITY. 

or broken galvanic current may be increased in size and strength. 
Hence for production of passive motion we find it an excellent agent. 
As a direct result of the tonic influence of electricity the disposition 
and capacity for mental labor increases. The lack of concentrative- 
ness and the loss of memory in nervous exhaustion rapidly disap- 
pear. Such symptoms as leucorrhoea, amenorrhoea, dysmenorrhoea, 
and purely functional menorrhagia accompanying nervous exhaus- 
tion may be successfully treated by electricity. It gives tone to the 
walls of the bloodvessels^ improves the important functions of the 
body. The remedy may be used generally over the body, locally or 
in both ways. If given locally the external or internal application 
may be selected, as the character of the case requires. If given 
locally, one pole may be placed over the spine and the other over the 
hypogastric region, or one pole may be placed against the cervix or 
in the cervical or uterine cavity. Currents thus given are well borne 
and often productive of much good. Subinvolution of the uterus, 
especially when not the result of laceration of the cervix, may be 
treated by this method ; one electrode may be introduced directly into 
the uterus. The contraction of the uterus thus produced relieves 
congestion of the organ, and changes are brought about which favor 
the absorption of the superfluous tissue. Doubtless some such 
rationale led Simpson to use the galvanic stem pessary. The use of 
electricity for the cure of nervous exhaustion is somewhat general. 
But when combined with massage, rest, seclusion, and overfeeding, 
according to the method of Dr. S. Wier Mitchell, the results are^ 
often but little short of miracles. 

To produce uterine contraction, to arrest bleeding, to empty the 
uterus of a body loose within its cavity, the faradic current will be 
found reliable. One pole may be placed upon the spine and the other 
over or against or within the uterus itself. As an adjunct "in the 
treatment of gynaecological cases electricity is often a good remedy.* 

* This chapter was written at the request of the author by E. Stansbiiry Sutton, 
M.D., of Pittsburgh, now lecturer on Gynaecology in the Spring Course of Lectures 
in Kush Medical College. 



I 



INDEX. 



Abdominal ovariotomy, 624 

supporters. 389 
Abortion, an effect of uterine disease, 229 

condition of the uteruo in, 230 

a predisposing cause of uterine dis- 
ease, 242 
Abscess of labia, 23 

following acute perimetritis, 365 
Absence, congenital, of the uterus, 121 

of labia, 25 

of vagina, 65 
Absorption, summary of cases of fibrous 

tumors cured by, 515 
Abstract of sympathetic influences of 
uterine disease and spermatorrhoea, 197 
Accident in injection, 311 
Accidents that may occur during ovariot- ' 
omy, 650 | 

Adhesions, complicating ovariotomy, 650 | 

of the labia, 17 

in adults, 18 

in children, 17 
After-treatment of ovariotomy, 654 
Alteratives, in the treatment of fibrous 
tumors of the uterus, 521 

local, in uterine disease, 319 
Amenorrhoea, 116 

as an effect of uterine disease, 227 

diagnosis, 120 

from retention, 120 

pathologv and morbid anatomv of, | 
117 

prognosis, 123 

symptoms, 117 

treatment, 124 

treatment by local electrization, 129 
Amputation of the cervix for chronic in- ! 

version, 426 
Ansemia, 291 
Anaesthesia, a sympathetic symptom of 

uterine disease, 210 
Anodvnes after ovariotomy, 656 
Anteversion, 382, 396 
Atresia vaginse, 66 
Atrophy of the Fallopian tubes, 667 

of the uterus, acquired, 122 

congenital, 122 

as the result of inflammation, 275 



Banning supporter, 390 

Baths, 303 

Battey's conclusions as to the proper cases 

for oophorectomy, 551 
Battey's operation, 546 



Battey's operation, physical and psychi- 
cal results of, 552 
Bearing-down pain, or uterine tenesmus, 
221 
not alwavs caused bv displace- 
ments, >23 
Becquerel's diagnostic summary between 
cancer and chronic inflammation of 
the cervix, 275 
Bernutz, conclusions in study of uterine 

haematocele, 171 
Binder, propriety of using after labor, 28 
Bladder, chronic inflammation of, 55 
diseases of, 51 
foreign bodies in, 63 
haemorrhage from, 53 
hyperfesthesia of, 54 
inversion of, 64 
irritable, 54 
paralysis of, 51 
stone in, 60 
Bozeman's apparatus for retaining the 
patient in position, 102 
operation for vesico-vaginal fistula, 
102 
Bowels, svmpathv of, in uterine disease, 

202 
Butlin, histologic distinction between 

sarcoma and carcinoma, 479 
Buttle's uterine scarificator, 317 
Byrne's cautery battery, 469 
cautery ecraseur, 469 
cautery electrodes, 470 

Calculus, vesical, 60 
Cancer of labia, 24 

of the uterus, 443 

causes of, 447 

Chian turpentine in, 451 

diagnosis, 448 

palliation of, 458 

symptoms of, 445 

treatment, 450 
Cancroid of the uterus, 464 
Caruncles of the urethra, 48 
Catheter, Goodman's for dilating the ure- 
thra, 60 

Skene's double perforated, 58 
Cautery battery, Byrne's, 469 

Ecraseur, Byrne's, 469 

electrodes, JByrne's, 470 
Caustic potassa in corroding ulcer of 

vulva, 46 
Cellulitis, 346 



676 



INDEX. 



Cervix uteri, elongation of, 342 
hypertrophy of, 341 
lacerations of, 329 
Change of life, 185 
Chronic perimetritis, 365 

treatment of, 369 
Clitoris, hypertrophy of, and nympha, 50 

treatment of, 50 
Condylomata of the vulva, 40 
Constipation, 292 
Corroding ulcer of the vulva, 46 
Cutter's method of electrolysis, 529 
Cystocle, 372 

treatment of, 374 
Cysts, dermoid, 567 

theories of origin, 574 

Dangers that may occur after uterine 

manipulation, 340 
Davidson's syringe, 307 
Delayed involution of the uterus, 428 
causes of, 428 
symptoms, 429 
treatment, 430 
Dermoid tumors, 567 

theories of origin, 574 
Diagnosis, 245-278 

of acute inflammation of unimpreg- 
nated uterus, 188 

acute vaginitis, 73 

amenorrhoea, 120 

cancer of the uterus, 448 

cellulitis, 352 

chronic vaginitis, 76 

displacements of the uterus, 384 

dysmenorrhea, 147 

endocervicitis, 273 

hyperinvolution, 442 

inversion of the uterus, 414 

lacerations of the cervix, 332 

menorrhagia, 133 

metatithmenia, 175 

ovarian tumors, 585 

paralysis of the bladder, 52 

perimetritis, 368 

stone in the bladder, 61 

submucous inflammation, 274 

urinary fistula, 83 
Diagnostic summary (Becquerel's) be- 
tween cancer and chronic inflammation 
of the cervix, 275 
Diiferential diagnosis of ovarian tumors, 

694 
Difiicnlt menstruation, 146 
Digital examination, 248 
Dilatation, 167 

of the uterus, 268 
Dilator, Hunter's, 167 

Molesworth's, 271 

Nelson's uterine, 167 
Dilators, tupelo, 270 
Disease of the bladder, 51 

labia and perinaeum, 17 

ovaries, 555 

vulva, 40 



Displacement of the ovaries, 555 
diagnosis, 558 
symptoms, 557 
treatment, 559 
Displacements of the vagina, bladder, 
and rectum, 372 
causes of, 378 
treatment, 386 
uterus, 376 
Division of sphincter vaginae in vaginis- 
mus, Sims's method, 71 
Drainage in ovariotomy, 627 
Dressing forceps, 263 
Dropsy of the Falloj^ian tubes, 667 

ovarian, 596 
Drvsdale's description of the ovarian cell, 

591 
Duverney's glands, phlegmon of, 21 
Dysmenorrhoea, 146 

as a symptom of fibrous tumors of 

the uterus, 498 
inflammatory form of, 148 
membranous, 150 
treatment of, 152 
neuralgic, 146 

treatment of, 147 
obstructive, 153 

treatment of, 156 

Ecraseur, amputation by, in hypertrophy 
of the cervix, 341 
Chassaignac's, 533 
Electricity, in diseases of women, 671 
in local treatment of amenorrhoea, 
129 
Electrolysis, 529 

Cutter's method, 529 
in ovarian tumors, 621 
treatment of fibrous tumors of the 
uterus by, 529 
Elephantiasis of labia, 24 
Elongation of the cervix, 342 
tensile, of the cervix, 343 
Emmett's knife for dividing the cervix, 
158 
speculum, 264 
Endocervicitis, 239 
diagnosis, 273 
gonorrhoea a frequent cause of 

chronic, 243 
in aged women, 240 
in virgins, 240 
Endometritis, 143, 192, 323 

application of iodized phenol in, 321 
Enucleation for removal of tumors of the 

uterus, 536 
Enucleator, Sims's, 538 
Entero- vaginal fistula, 107 

vesical fistula, 107 
Epithelial cancer of the uterus, 464 
Epithelioma of the uterus, 464 
diagnosis, 466 
structure of, 467 
treatment, 468 
Ergot, causes of failure of, 526 



INDEX. 



677 



Ergot, dangers from use, in fibrous tumors 
of the uterus, 528 
different preparations, 518 
hypodermic injections of, 520 
in fibrous tumors of the uterus, 499 
in paralysis of the bladder, 53 
in uterine hemorrhage, 138, 143, 144 
mode of action, 521 
using, 516 
Etiology of uterine disease, 241 
Extirpation of the uterus, 473 
Excrescences, urethral, 48 
Exsecting the uterus, Lane's operation, 
473 

Fallopian tubes, 666 

cancer of, 667 
dropsy of, 667 

hypertrophy and atrophy of, 667 
inflammation of, 666 
tumors (hydrosalpinx), 357 
Fibrous tumors of the uterus, 481 
diagnosis, 489 
nature of, 483 
prognosis, 491 
symptoms, 485 
treatment, 495 
Fistula, urinary, 81 

Bozeman's method for cure, 102 
diagnosis, 83 
entero- vaginal, 107 

vesical, 107 
recto-vaginal, 107 

treatment of, 108 
Simons's method for cure, 95 
Sims's operation, 86 
Fistulous opening as a means of treat- 
ment in ovarian tumors, 617 
Fitch's abdominal supporter, 389 

measuring sound, 255 
Follicular vulvitis, 42 
causes of, 43 
treatment, 43 
Foreign bodies in the bladder, 63 

Galvano-cautery, 468 
Gangrenous vulvitis, or noma, 47 
Gastrotomy, modification of operation, by 
Dr.Leon Labbe, 544 
for removal of tumors of the uterus, 
544 
Generation, afiected by uterine disease, 

228 
Genu-pectoral position in treatment of 

displacement of the uterus, 388 
Gillette's, Dr., operation for rectocele, 375 
Glycerin, depletion by means of, 318 
Gonorrhoea, a cause of chronic endocer- 
vicitis, 243 
a cause of local peritonitis, 357 
and endometritis, 243 
Goodell's operation for supra-vaginal 

elongation of cervix, 344 
Goodman's catheter in chronic inflam- 
mation of bladder, 60 



Granular cell of ovarian tumor, 591 

Drysdale's description of, 591 
Gum-elastic air-bag to restore the in- 
verted uterus, 421 

Hackenberg's method of treating pro- 
lapse, 401 
Hsematoceie, chronic retrouterine, 179 

periuterine, 170 

uterine, 171 
Haemorrhage, as a symptom of fibrous 
tumors of the uterus, 496 

during menstruation, 133 

in nursing women, 142 

following ovariotomy, 659 

from the bladder, 53 
Haemorrhagic diathesis, 136 
Higby's speculum, 260 
Huguier's gland, labial abscess from in- 
flammation of duct, 23 
Hunter's dilator, 167 
Hydrosalpinx, 357 
Hymen, hyperaesthesia of, 70 

treatment, 71 
Hyperaemia, 234 
Hyperaesthesia, 209 

of the bladder and urethra, 54 

of vulva and hymen, 70 
Hyperinvolution, 441 
Hypertrophied labia, 24 
Hypertrophy of the cervix, 341 

of the clitoris and nympha, 50 
treatment, 50 

of the Fallopian tubes, 667 

of the ovaries, 555 

of the uterus, 274 
Hysterectomy, modification, by Dr. Leon 

Labbe, 544 
Hystero-epilepsy, 205 
Hysterometer, 258 

method of applying, 259 
Hysteropathy, 193, 233 

Inflammation, acute, of the mucous mem- 
brane of the uterus, 191 

of the unimpregnated uterus, 188 

characteristic signs of, 272 

chronic of the bladder, 55 

treatment of, 57 

Sims's method of treatment, 60 

erythematous, papular, vesicular, and 
pustular, of the vulva, 41 

of- the ovaries, 561 
treatment of, 563 

vesicular of vulva, 44 
Injections, 306 

accidents in, 311 

manner of using, 307 

medicated, 308 

intrauterine, 328 

of the sac in ovarian tumors, 615 
Intrauterine injections, 328 

pessary, Simpson's, 130, 442 
Inversion of the bladder, 64 

of the uterus, 412 



678 



INDEX. 



Inversion of the nterus, symptoms of, 413 

prognosis, 415 

treatment, 416 
Involution, 428 

delayed, 428 

treatment of, 430 

of the uterus, diseased deviations of, 
428 
Iodized phenol, 321 

Jenks's, Professor Edward W., method of 
denuding in perinseorrhaphy, 35 
uterine probe, 254 
uterine sound, 254 
Jennison's exploring and indicating 
sound, 255 

Kolpokleisis, 302 

Labb^'s, Dr. Leon, modification of the 
operation of hysterectomy as applied to 
fibrous tumors (exsanguinification of 
the tumor), 544 
Labia, abscesses of, 23 

absence of, 25 

adhesions of, 17 

cancer of, 24 

hypertrophied, 24 

oedema of, 20 

phlegmon of, 21 

sanguineous infiltration of, 19 

tumors of, 23 

varices of, and vulva, 20 

wounds of, 18 
Lacerations of the cervix uteri, 329 

operations for, 334 
Laminaria tents, 269 
Lane's operation (pervaginal enucleation 

of the uterus), 474 
Laparo-hysterotomy, 542 
Laparotomy, 541 
Lapse (falling of the womb), 379 
Leeches, application to uterus, 316 
Lever for dilating the vagina, 266 
Leucorrhoea, an evidence of disease of 
uterus, 221 

a symptom of tumors of the uterus, 
486 
Ligature in ovariotomy, 626 
Linen test for minute urinary fistulse, 104 
Lithotomy, 63 
Lithotrity, 62 

Liver, sympathy of, in uterine disease, 203 
Local congestions in uterine disease, 291 
Local peritonitis, 355 

diagnosis of, 358 
Local symptoms of uterine disease, 219 

Mammary bodies excited by uterine dis- 
ease, 215 
Medicated pessaries, 314 
Membranous dysmenorrhoea, 150 

treatment of, 152 
Menopause, 185 
Menorrhagia, 133, 227 



Menorrhagia, frequent in endooervicitis, 
227 
treatment of, 137 
Menstruation and its disorders, 110 

effects of partial closure of the os 

uteri on, 225 
haemorrhage during, 133 
misplaced, 170 
pain during, 225 
Mercury, acid nitrate of, as a local altera- 
tive, 321 
Metatithmenia, 170 

treatment of, 177 
Metrorrhagia, 133 

treatment of, 137 
Metrotome, Dr. Peaslee's, 164 
Microscopic examination of ovarian fluid, 

566 
Mcintosh's natural uterine supporter, 395 
Moles worth's dilator, 271 
Mucous inflammation of uterus, 238 
Mucous membrane of uterus, acute in- 
flammation of, 191 

Nelson's speculum, 261 

uterine dilator, 167 
Nervous prostration in uterine disease, 

286 
Nervous system, sympathetic aflfections 

of, 203 
Neuralgia of the coccyx, 668 

treatment of, 669 
Nitrate of silver, application in vaginis- 
mus, 72 
as a local alterative, 322 
Noeggerath, Dr. Emil, treatment of small 

ovarian cysts, 621 
Noma, 47 
Nott's operation for cure of coccygodynia, 

670 
Nott's speculum, 260 
Nott's tenaculum forceps, 264 
Nympha, hypertrophy of the clitoris and, 
50 

Obstructive dysmenorrhoea, 153 

Peaslee's conclusions in, 159 

Sims's operation for, 157 

treatment of, 156 
Occlusion of the vagina, 17 
QEdema of the labia, 20 
Oophorectomy, 546 
Operating chair, 246 
Operating table, 247 
Organic disease complicating ovariotomy, 

637 
Os and cervix, appearance of in the aged, 
267 

in the multiparous uterus, 266 

in the virgin, 266 
Os, stenosis of external, 163 

of internal, 162 
Os uteri, in the aged, 257, 267 

how to find the, 262 
Ovarian cell, described by Drysdale, 591 



1 



INDEX, 



679 



Ovarian dermoid tumors, 567 
theories of origin, 574 
fluid, microscopical examination of, 

566, 591,593 
tumors, 564 

anatomy of, 564 
causes of, 582 

differential diagnosis of, 594 
exploration by means of the as- 
pirator, 591 
granular cell of, 591 
general remarks on the diag- 
nosis of, 585 
inflammation and ulceration of, 

578 
injection of the sac of, 615 
modes of termination of, 580 
pressure in conjunction with tap- 
ping in treatment of, 612 
prognosis of, 584 
tapping as a palliative means in, 

604 
treatment, 602 

of the pedicle, 624 
Ovaries, 553 

affections of, 555 
congenital atrophy of, 555 
displacements of, 555 
hypertrophy of, 555 
inflammation of, 561 
the method of examining, 553 
tumors of, 564 
Ovaritis, 561 

treatment, 563 
Ovariotomy, abdominal, 624 

accidents that may occur during, 650 
adhesions complicating, 650 
after-treatment of, 654 
complicated by organic diseases, 637 

by pregnancy, 628 
drainage in, 627 
ligature in, 626 
preparatory steps, 639 
remarks and personal statistics, 664 
vaginal, 622 
wounds of the stomach and intestines 

complicating, 651 
wounds of the urinary organs and 
gall-bladder, 651 

Pain, attendant upon uterine inflamma- 
tion, 225 
Painful menstruation, 225, 145 
Palpitation, a sympathetic symptom of 

uterine disease, 212 
Papin's Dr. J. L., method of dilating 

the urethra, 58 
Paquelin's thermo-cautery, 468 
Paralysis of the bladder, 51 
diagnosis, 52 
prognosis, 51 
symptoms, 51 
treatment, 52 
Partial closure of the os uteri, effects on 
menstruation, 225 



Parturition a predisposing cause of uterine 

disease, 242 
Pathology of hysteropathy, 233 
Pea-lee's conclusions in obstructive dys- 

inenorrhoea, 159 
IVaslee's metrotome, 164 
Pedicle, treatment of in ovariotomy, 624 
Pelvic peritonitis, 355 
Perineorrhaphy, 35 
Periufeum, 26 

effects of laceration, 30 
rupture of the, 29 
immediate operation for, 33 
prevention of, 31 
treatment, 31 
spontaneous cure, 32 
Perimetritis, acute, 346 
symptoms, 349 
treatment, 360 
chronic, 365 

symptoms and diagnosis, 368 
Peritonitis, following uterine manipula- 
tions, 339 
local, 355 
diagnosis, 358 
symptoms, 357 
Periuterine hsematocele, 170 
Pervagiual enucleation of the uterus. 
Lane's operation, 474 
: Pessaries, 390 

medicated, 314 
Pessarv : Cutler's, 394 : Gehring's, 392 ; 
Hewitt's, 392; Thomas's, 397; 
Scott's, 393 ; Smith's, 391 ; Zwank's, 
392 
Simpson's intrauterine, 130, 442 
Phlegmon of the labia, 21 
Plethora, 291 

Plugging in uterine haemorrhage, 139 
Sims's method, 139 
Thomas's method, 141 
Polypoid tumors, removal of, 531 
Pregnancy, a predisposing cause of uter- 
ine disease, 242 
■ complicating ovariotomy, 628 
complications with fibrous tumoi-s of 

the uterus, 492 
growth of uterine tumors during, 

488 
injections and baths in, 313 
retroversion and retroflexion during, 
407 
Pressure, in conjunction with tapping in 

treatment of ovarian tumors, 612 
Probe, object in using, 253 

mode of using, 257 
Prolapse, 380, 400 

Brown's operation, 405 
Hackenberg's method of treatment, 

401 
Sims's operation, 403 
Protrusion of the uterus, 381 
Pruritus pudendi, 43 

treatment, 44 
Puberty, 111 



680 



INDEX. 



Purulent vulvitis, 41 
treatment, 41 

Quinine, 297, 664 

use in dysmenorrhoea, 148 

Eadical treatment of inversion of the 

uterus, 419 
Rectal examinations, 252 
Rectal injections after ovariotomy, 657 
Rectocele, 372 

treatment, 874 

complicating laceration of the per- 
inseum, 38 
Recto-vaginal fistula, 107 

treatment, 108 
Renal lesions complicating ovariotomy, 

652 
Repositor, White's, in inversion of the 

uterus, 420 
Retention of urine, an effect of inflam- 
mation of the urethra, 52 
Retroflexion during pregnancy, 407 

treatment, 410 
Retrouterine hsematocele, chronic, 179 

treatment, 183 
Retroversion, 382, 397 

and retroflexion during pregnancy, 

407 
treatment, 410 
Rupture of the perinseum, by injudicious 
use of ergot, 30 
by unskilful use of the forceps, 29 
prevention of, 31 

Sanguineous infiltration of labia, 19 
Sarcoma of the uterus, 443 

diagnosis, 479 

histological distinction between, and 
carcinoma, 479 

treatment, 480 
Savage's definition of the perinfeum, 26 
Sawyer's round knife for denuding sur- 
face, 336 
Scarification of the cervix, 316 
Scarificator, uterine, 317 
Sea-tangle tents, 269 
Senility, 185 
Septicaemia, 461 

following ovariotomy, 662 

treatment, 663 
Serre-fine in rupture of perinseum, 34 
Shield, Wilson's, 472 
Shock following ovariotomy, 658 
Simon's operation for urinary fistula, 95 

retractors, 266 

speculum, 265 
Simpson's intrauterine pessarv, 130, 
442 _ 

operation for cure of coccygodynia, 
670 

uterine sound, 253 
Sims's depressor, 264 

guarded hooks, 538 

method of examination, 263 



Sims's method of plugging in uterine 
haemorrhage, 139 
in menorrhagia, 139 
operation for chronic inflammation 
of the bladder, 60 
for obstructive dysmenorrhoea, 

157^ 
for urinary fistula, 86 
Skene's double perforated catheter, 58 
Slippery elm tents, 325 
Smith's , Dr. Albert H., knife for perinse- 
orraphy. 37 
pessary, 391 

Thomas's modification, 391 
Dr. Tyler's mode of restoring the in- 
verted uterus, 421 
Sorbefacient treatment of fibrous tumors 

of the uterus, 499 
Spaying, 546 

Speculum, mode of using, 262 
Spermatorrhoea, sympathetic influences 

of, 197 
Spinal cord, sympathetic aflfections of, in 

uterine disease, 209 
Spielberg, Professor O., diagnosis of can- 
cerous infiltration, 277 
Sponge-tents, 269 
Statistics, remarks and personal, upon 

ovariotomy, 664 
Stenosis, 153 

treatment, 157 

complicating endometritis, 324 
of the external os, 163 
of the internal os, 162 
Sterility, an efifect of uterine disease, 228 
Stomach, sympathy in uterine disease, 200 
Stone in the bladder, 60 

treatment, 62 
Storer, Professor D. H., comparative 
merits of incision and dilatati on in 
dysmenorrhoea, 168 
Strychnia in paralysis of the bladder, 53 
Subinvolution of the uterus, 433 
diagnosis, 437 
treatment, 438 
Submucous inflammation of the uterus, 

diagnosis of, 274 
Superficial trachelotomy, 161 
Suppuration following acute perimetritis, 

365 
Supporters, 389 
Supravaginal elongation of the cervix, 342 

Goodell's treatment of, 344 
Surgical operation for relief of haemor- 
rhage, 535 
Brown's operation, 535 
treatment of fibrous tumors, 531 
of prolapse, 402 
Suspension pessaries, 395 
Sympathetic influences of uterine dis- 
ease, 193 
and spermatorrhoea abstract of, 197 
symptoms of uterine disease, 200 
Syringe, Davidson's, 307 
fountain, 307 



I 



INDEX. 



681 



Tampon, .glycerin, 318 

Tampon in uterine hiiemorrhage, 139 

Thomas's method, 141 
Tapping, as a palliative in ovarian tu- 
mors, 604 
Tents, 269, 327^ 

Tensile elongation of the cervix, 343 
Thermo-cautery, Paquelin's, 468 
Thomas's anteversion pessary, 397 
Tincture of the chloride of iron in pruri- 
tus pudendi, 45 
Trachelorrhaphy, 334 
Trachelotomy, superficial, 161 
Traumatic peritonitis following ovariot- 
omy, 660 
Treatment of abscess of the vagina, 67 
abscess of the labia, 23 
acute inflammation of the unimpreg- 

nated uterus, 188 
acute vaginitis, 74 
adhesions of the labia, 17 
amenorrhoea, 124 

by local electrization, 129 
atresia vaginae, 67 
cancer of labia, 24 
of uterus, 450 
chronic retrouterine hfematocele, 183 
chronic perimetritis, 360 
chronic vaginitis. 77 
condylomata of vulva, 40 
displacements of uterus, 386 
endometritis, 323 
epithelioma of the uterus, 468 
hypersesthesia of the bladder, 54 
hvpertrophv of clitoris and uvmpha, 
50 * 
of labia, 24 
inversion of the bladder, 64 
of uterus, 416 
chronic form of, 418 
Treatment of lacerations of the cervix. 
333 
of perinseura, 31 
menorrhagia, 137 

nausea and vomiting after ovariot- 
omy, 656 
neuralgia of the coccyx, 668 
obstructive dysmenorrhoea, 156 
oedema of labia, 20 
ovarian tumors, 602 

bv means of a fistulous opening, 

'617 
medical, 610 
ovaritis, 563 
paralysis of the bladder, 
pedicle in ovariotomy, 624 
perimetritis, 360 
phlegmon of labia, 22 
prolapse, 400 
puerperal vaginitis, 78 
purulent vulvitis, 41 
■ rectocele and cystocele, 374 
retroversion and retroflexion during 

pregnancy, 410 
sanguineous intiltration of labia, 19 



Treatment of septicaemia after ovariot- 
omy, 663 
surgical, of fibrous tumors of uterus, 

531 
urinary fistula, 84 
uterine disease, general, 278 
local, 315 
special, 303 
vaginismus, 71 
varices of labia, 20 
wounds of, IS 
Trocar, I'itch's, 643 
Tumors, labial, 23 
in the vagina, 70 
of the uterus, 481 

complicated with pregnane v, 

492 
diagnosis of, 489 
growth during pregnancy, 488 
prognosis, 491 
treatment, 496 
ovarian, 564 
Tupelo dilators, 270 
Tympanites alter ovariotomy, 657 

Ulceration and abrasion as results of hy- 

pertemia, 237 
I Urethra, caruncles of. 43 
I excrescences of, 48 

treatment, 49 
foreign bodies in, 63 
hyperaesthesia of, 54 
irritable bladder and, 54 
vascular, 49 
Urinary fistula, 81 
treatment, 84 
Uterine dilator, Hunter's, 167 
Nelson's, 167 
disease, 193 

a cause of abortion, 229 
diagnosis of. 245 

efiect upon generation, 228 
upon labor, 231 
upon post-partum condi- 
tion, 231 
' etiology of, 241 

( sympathetic influence of, 197 

I sympathetic symptoms, 200 

i treatment, general, 278 

local, 315 
special, 303 
haematocele, 171 

Bernutz's conclusions upon 

study of, 171 
diagnosis of, 175 
symptoms, 173 
treatment, 177 
haemorrhage, 133 
treatment, 137 
use of ergot in, 138 
inertia, 428 

inflammation, pain of, 225 
manipulation and operation, unto- 
ward effects of, 339 
scissoi-s, 336 



682 



INDEX 



Uterine tenesmus, 221 
Uterus, absence of, 121 

acute inflammation of mucous mem- 
brane of, 191 
acute inflammation of unimpreg- 
nated, 190 

treatment, 190 
atrophy of, acquired, 122 

as a result of inflammation, 275 

congenital, 122 
cancer of, 443 

treatment, 450 
dilatation of, by means of tents, 268 
extirpation of, 473 

Freund's operation for, 473 

vaginal, 474 
hyperinvolution of, 441 
inversion of, 412 

treatment, 416 
involution of, 428 

treatment, 430 
mucous inflammation of, 238 
subinvolution, 433 

treatment, 438 
tumors of, 481 

Vagina, absence of, 65 

fistulous opening of, for treatment of 

ovarian tumors, 620 
tumors of, 70 
Vaginae, atresia, 66 

treatment, 67 
Vaginal extirpation of the uterus, 474, 
Schroeder's operation, 476 
ovariotomy, 622 
Vaginismus, 70 

division of sphincter, Sims's method 
for, 72 



Vaginismus, forcible dilatation in, 72 
Vaginitis, acute, 73 

treatment, 74 
chronic, 75 

treatment, 77 
puerperal, 78 

treatment, 80 
Varices of labia and vulva, 20 
Vascular tumor of urethra, 48 

urethra, 49 
Vesical calculus, 60 

lesions complicating ovariotomy, 652 
Vesico-vaginal fistula, Simon's method, 95 

Sims's, 86 
Vesicular inflammation of vulva, 44 
Vulva, condylomata of, 40 
corroding ulcer of, 46 
diseases of, 40 
hypersesthesia of, 70 

treatment, 71 
inflammations of, 41 

treatment, 41 
varices of, and labia, 20 
vesicular inflammation of, 44 
Vulvitis, follicular, 42 
treatment, 43 
gangrenous, 47 
purulent, 41 

White's repositor, 420 
Wilson's operating chair, 246 

shield, addition to the thermo-cau- 
tery, 472 
Wounds of the intestines complicating 
ovariotomy, 651 
of labia, 18 

of urinary organs complicating ovari- 
otomy, 651 



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